Republic of the PhilippinesDepartment of Health

OFFICE OF THE SECRETARY

March 16, 2020

DEPARTMENT MEMORANDUMNo. 2020 - 0123

FOR: ALL UNDERSECRETARIES AND ASSISTANT SECRETARIES;DIRECTORS OF BUREAUS, SERVICES, AND CENTERS FORHEALTH DEVELOPMENT(CHD); MINISTER OF HEALTH -BANGSAMORO AUTONOMOUS REGION IN MUSLIM MINDANAO(MOH-BARMM); EXECUTIVE DIRECTORS OF SPECIALTYHOSPITALS; CHIEFS OF MEDICAL CENTERS, HOSPITALS ANDSANITARIA; AND ALL OTHERS CONCERNED

SUBJECT: Interim Guidelines on the Management of Surge Capacity through theConversion of Public Spaces to Operate as Temporary Treatment_andMonitoring Facilities for the Management of Persons Under Investigationand Mild Cases of Coronavirus Disease 2019 (COVID-19)

I, BACKGROUND

On March 10, 2020, the Philippines was declared to be under Alert Level 4, Code RedSublevel 2. Over the succeeding days, with the number of COVID-19 cases observed to rise,the capacities of all our health facilities are expected to be fully utilized.

In order to reduce the exposure of the general population to COVID-19 patients andenhance the surge capacity of our existing health facilities, the Department of Health (DOH)hereby issues these interim guidelines to provide guidance for health managers and amongLocal Government Units (LGU) to improve the surge capacity of the local health system byidentifying and converting viable public spaces such as auditoriums, gymnasium, classrooms,vacant hotels, courts, open fields with tents, and the like as temporary treatment andmonitoring facilities to manage COVID-19 PUIs and confirmed cases of mild COVID-19.

I. OBJECTIVE

This shall provide guidance in managing the potential surge of COVID-19 patients indifferent health facilities through the identification, assessment and conversion of viablepublic spaces into temporary treatment and monitoring facilities.

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila # Trunk Line 651-7800 local 1108, 1111, 1112, 1113Direct Line: 711-9502; 711-9503 Fax: 743-1829 @ URL: http://www.doh.gov.ph; e-mail: fiduque@doh.gov.ph

Ill. SCOPE AND COVERAGE

These interim guidelines shall cover all LGUs and health managers who requiretemporary treatment and monitoring facilities

IV. GENERAL GUIDELINES

A. Urban health centers and rural health units are enjoined to provide services for 24 hours,7 days a week, or operate on an on call basis after office hours.

The health manager or LGU may identify and consider converting public spaces intotemporary treatment and monitoring facilities when necessary, to cater to the increasingnumber of Persons Under Investigation (PUI) and cases of COVID-19 patients withmild symptoms in the following conditions:1. Municipality, City, or Province has declared an enhanced community quarantine;2. Current health facilities are operating nearing its maximum surge capacity.

Possible areas that may be converted include auditoriums, gymnasium, classrooms,vacant hotels, courts, and open fields with tents. They may consider partnership withNon-Government Agencies and Private Sector for the use of these public spaces.

Operations of these temporary treatment and monitoring facilities shall be under thesupervision of the City/Municipal Health Officer who shall assign a facility managerwhen necessary, and shall serve as an extension of their Urban Health Centers/RuralHealth Units.

These treatment facilities shall provide the following services:1.Outpatient Services

a) Consultation for patients experiencing mild respiratory symptoms (fever, cough,colds, etc.);

b) Provision of supportive treatment and psychosocial service;

2.Treatment and monitoring services for PUIs who do not have optimal isolation spacein their homes, and confirmed COVID-19 patients with mild symptoms, whichincludes vital signs monitoring, appropriate clinical management;

3.Timely referral to appropriate health facilities as needed.

The health manager or LGU may develop mechanisms to ensure coordination withUrban Health Centers/Rural Health Units and access to higher centers or healthfacilities that provide intensive care services and for proper and timely referral ofpatients as indicated in Department Memorandum No. 2020-0072, “Interim Guidelinesfor 2019 Novel Coronavirus Acute Respiratory Disease (2019-nCOV ARD) Responsein Hospitals and Other Health Facilities (ANNEX A).

G. Conversion of public spaces into temporary treatment and monitoring facilities shallfollow principles and protocols related to Infection Prevention and Control. ConfirmedCOVID-19 patients may be placed in shared space or rooms. PUIs shall be separated ina different space/tent/room provided with individual enclosed spaces and separateentrance.

H. The health manager or LGU shall ensure the provision of basic needs for patients, suchas food, water, sanitation, and communication.

I. The temporary treatment and monitoring facility shall be limited only to health workersand patients. No visitors shall be allowedin the area.

J. The temporary treatment and monitoring facility shall provide for infection controlmeasures, water, sanitation and hygiene facilities including but not limited toavailability of toilets, solid waste management/disposal, vector control and other similar/related health requirements.

V. SPECIFIC GUIDELINESA. Patient Management

1.Patients classified as Persons Under Investigation (PUI)a) May be accommodated in temporary treatment and monitoring facilities provided

they are in separate isolation rooms that meet the standards on converted privaterooms detailed in Department Memorandum No. 2020-0062, "Guidelines on theStandards of Airborne Infection Isolation Room and Conversion of Private Roomsand/or Wards into Temporary Isolation Rooms for the Management of PatientsUnder Investigation (PUI) for 2019 Novel Coronavirus (nCOV)" (ANNEX B).

b) In compliance with Infection Prevention and Control standards, PUI cannot becohorted together.

2. Confirmed COVID-19 with mild symptoms, no comorbidities, and aged 18-60 yearsmay be accommodated and managed in the converted treatment and monitoringfacilities.

3.Confirmed COVID-19 with severe symptoms, with comorbidities, aged 0-18 or 60years and above maybe referred to the nearest Level 2 or Level 3 hospital acceptingPUIor confirmed COVID-19 patients for appropriate management.

B. Location FeaturesIdentified space should:

1. Be accessible within a maximum of two (2) hours to a Level 2 or Level 3 hospitalaccepting PUI or confirmed COVID-19 patients;

2. Have uninterrupted access to electricity, potable water source, and sewerline;

C. Minimum Infrastructure Requirement1.Temporary treatment and monitoring facilities must be fully enclosed with adequate

lighting;

2.There should beat least fan ventilation to be provided;

3.There should be a separate entrance and exit for the patients and healthcare workers;

4.The facility should be divided into three (3) zones namely: contaminated, buffer andsterile zones.a) Contaminated Zone: serve as the area where patients are admitted/ contained.b) Buffer Zone: serves as an area for doffing of PPE, decontamination, and hand

hygiene.c) Sterile Zones: serves as holding area and entrance for healthcare workers, and the

area for Personal Protective Equipment (PPE) donning of health workers.

5.Distance between patient beds should be maintained atleast 3 feet apart on all sides;

6.Temporary partitions should be provided to ensure patient privacy (i.e. drapes or lowwalls) for COVID-19 patients placed in a shared space or room.

7.4 backup supply of electricity and free-flowing water for at least 72 hours must beensured, in case of water and power interruption;

8.The provision of fixed or temporary plumbing fixture per person must follow thefollowing requirements:a) Ratio requirements:

(1)One(1) water closet per 25 males and one (1) per 20 females(2)One (1) urinal per 10-50 males, adding one (1) fixture for each additional 50

males(3)One(1) lavatory for every 10 males and one (1) for every 10 females(4)One (1) showerper 8 persons

b) Confirmed cases of COVID-19 may share toilets and showers. Regulardisinfection should be practiced in accordance with DM 2020-0072 (see ANNEXA).

c) A dedicated toilet and shower for each PUI should be provided when possible. Incases where this arrangement is not feasible, the toilet/shower facilities must bedisinfected after every use.

9.There may be provision or access to laundry services.

D. Minimum Medicines, Medical Supplies, and Equipment Requirement:1.The LGU must ensure the availability of necessary medicines and medical supplies

for supportive treatment and emergency care (Annex C);

2.The temporary treatment and monitoring facilities must have access to at least asecondary clinical laboratory and basic radiologic services such as X-ray.

E. Minimum Human Resources Requirements:1.The LGU may source from its health network or private sector partners the necessary

human resources needed to operationalize the temporary treatment and monitoringfacility to ensure a 24/7 operation.

2.Each temporary and treatment monitoring may have the following minimum humanresource:

a) At least one (1) Physician per shiftb) At least three (3) Nurses per shift (1 Nurses: 12 Patients)c) Support Staff

(1)Atleast two (2) security personnel per shift (1 for each entrance).(2)At least one (1) maintenance staff per shift

3.The LGU may likewise provide the following additional human resources as the needarises:a) At least one (1) pharmacist per shift (1 pharmacist:100 patients)b) At least one (1) nutritionist-dietitian (1 ND:50 patients)c) At least one (1) medical social worker per shift (1 MSW:25 patients)d) At least five (5) food handlers: (10:100 patients)

4.The LGU should also ensure the availability of psychosocial interventions forhealthcare workers deployed in these temporary treatment and monitoring facilities.

F. Minimum Requirements for the Adherence to Infection Prevention and Control1.Adequate Personal Protective Equipment (PPE) must be provided to both patients and

all healthcare workers and deployed in these facilities, which may include:a) For healthcare workers

(1)Surgical masks(2)Gowns(3)Goggles/face shields(4)N95 respirators

b) Forpatients(1)Surgical masks

2.Rational use of the provided PPE must be ensured.

G. Minimum Requirements for Healthcare Waste Management1.Segregation, collection, and handling of all waste generated from these temporarytreatment and monitoring health facilities may abide by the principles of healthcarewaste management.

2.LGUs may refer to DM No. 2020-0072 in Annex A for a more detailed guide onhealthcare waste management for highly infectious waste and the appropriatetreatment of soiled linens and clothes.

H. Availability of Transport and Referral Protocols1.All temporary treatment and monitoring facilities shall have access to at least a Type I

Basic Life Support (BLS) Ambulance as defined in the Administrative Order No.2018-0001, “Revised Rules and Regulations Governing the Licensure of LandAmbulances and Ambulance Service Providers.”

2.All patients whose symptoms progressed may be referred to a facility with intensivecare services. Referral to these health facilities may be in accordance with DepartmentMemorandum No. 2020-0108, “Guidelines for Management of Patients with Possibleand Confirmed COVID-19” and its amendments.

For guidance and strict compliance.

By Authority of the Secretary of |Health

[JLILIBETH C. DAVID, MD, MPH, MPM, CESO IUndersecretary of HealthHealth Facilities Infrastructure and Development Team

ANNEX ARepublic of the PhilippinesDepartment of Health

OFFICE OF THE SECRETARY

February 3, 2020

DEPARTMENT MEMORANDUMNo, 2020 - 9072.

TO: ALL UNDERSECRETARIES AND ASSISTANT SECRETARIES;DIRECTORS OF BUREAUS AND CENTERS FOR HEALTHDEVELOPMENT; MINISTER OF HEALTH —~ BANGSAMOROAUTONOMOUS ___REGION _IN_ _MUSLIM__ MINDANAO):EXECUTIVE DIRECTORS OF SPECIALTY HOSPITALS ANDNATIONAL NUTRITION COUNCIL: CHIEFS OF MEDICALCc S. SPITALS, SANIT: TTUTES:P T PHILIP.CORPORATION; DIRECTORS OF PHILIPPINE NATIONALAIDS COUNCIL AND TREATMENT AND REHABILITATION

CENTERSANDOTHERS

CONCERNEDSUBJECT: terim Guidelines for 2019 Novel ‘onavirus Acute Respirato:

Disease (2019-nCoV_ ARD) Response in Hospitals and Other HealthFacilities

I. BACKGROUND

After a cluster of pneumonia cases of unknown etiology was reported in Wuhan City,Hubei Province of China last December 31, 2019, Chinese health authorities preliminarilyidentified the cause of this viral pneumonia as a new or novel type of coronavirus(2019-nCoV).

With an increasing number of cases spreading to various territories and confirmedhuman-to-human transmission, the World Health Organization declared the outbreak as aPublic Health Emergency of International Concern (PHEIC) last January 30, 2020.

The Department of Health (DOH) hereby issues these interim guidelines for all healthfacilities and institutions whether public or private on the necessary precautions,preparations ofthe health facilities, and management of persons under investigation (PUI)and confirmed cases of the 2019-nCoV ARD.

Il. GENERAL GUIDELINES

1. All Level 2 and Level3 hospitals shall attend to all PUIs.2. All hospitals and health facilities shall establish and maintain an Infection Prevention

and Control Committee (IPCP) in the health facility, headed by an infection controlphysician and infection control nurse. The IPCP shall be responsible for theformulation, implementation, and monitoring of policies, guidelines, and proceduresrelated to infection control. (Refer to the National Standards in Infection Control forHealthcare Facilities, 2009 Edition)

Building }, San Lazaro Compound, Riza! Avenue, Sta. Cruz, 1003 Manila # Trunk Line 651-7800 local 1108, i111, 1112, 1113Direct Line: 711-9502; 711-9503 Fax: 743-1829 @ URL: http://www.doh.gov.ph; e-mail: ftdique@doh.gov.ph

3. All hospitals and health facilities shall ensure that all hospital personnel are familiarwith and adhere to infection prevention policies, guidelines, and procedures of thehospital, and shall be protectedatall times since they are the first in line for exposure.

4, All hospitals and health facilities shall ensure that all resources and contingenciesneeded for the implementation of infection prevention and control measures areadequately available.

5. All hospitals and health facilities shall ensure that appropriate personal protectiveequipment (PPE)are appropriately used by patients and hospital personnel, accordingto existing protocols.

YI. SPECIFIC GUIDELINES

A. Infection Prevention and Control

Universal precautionary measures are implemented in all health facilities. However, foran emerging infectious disease event such as the 2019-nCoV ARD, standard preventionand control strategies must be employed.

IPC strategies to prevent or limit infection transmission in health-care settings are,

summarized in Annex A.

B. Case Definition

1, Patient under Investigation (PUDClinical features and epidemiological risk should be considered in identifyingpersons as PUI for 2019-nCoV ARD. A person meeting the following criteriashould be evaluated as a PUI in association with the outbreak of 2019-nCoVARD:

a) A person with Severe Acute Respiratory Infection (SARD, with history offever and cough requiring admission to hospital, with no other etiology thatfully explains the clinical presentation (clinicians should also be alert to thepossibility of atypical presentations in patients who areimmunocompromised), and ANY ofthe following:

(i) A history of travel to China and other 2019-nCoV ARD affectedareas in the 14 days prior to symptom onset.

(2) The disease occurs in a health care worker who has been working inan environment where patients with severe acute respiratoryinfections are being cared for, without regard to place of residence orhistory oftravel;

(3) The person develops an unusual or unexpected clinical course,especially sudden deterioration despite appropriate treatment,without regard to place of residence or history of travel, even ifanother etiology has been identified that fully explains the clinicalpresentation.

ORb) Individuals with acute respiratory illness of any degree of severity who,

within 14 days before onset of illness, had ANY ofthe following exposures:(1) Close physical contact with a confirmed case of 2019-nCoV ARD

infection, while that patient was symptomatic;

(2) A healthcare facility in a country where hospital associated2019-nCoV ARD infections have been reported;

(3) Direct contact with animals Gf animal source is identified) incountries where the 2019-nCoV ARD is known tobe circulating inanimal populations or where human infections have occurred as aresult of presumed zoonotic transmission

PUIs may present a range of signs and symptoms from mild, moderate, orsevere illness; the latter includes severe pneumonia, ARDS, sepsis and septicshock. (See page 3 of Annex B for clinical manifestation of 2019-nCoV ARD)The criteria and the DOH decision tool (Annex C) shall be used to guideevaluation.

Close ContactPersons visiting patients or staying in the same close environment of a2019-nCoV ARD confirmed case whoare either:a) Within approximately 6 feet (2 meters), or within the room orcare area, of a

confirmed case for a prolonged period of time while not wearingrecommended personal protective equipment or PPE (e.g., gowns, gloves,NIOSH-certified disposable N95 respirator, eye protection); OR

b) Having direct contact with infectious secretions of a novel coronavirus case(e.g., being coughed on) while not wearing recommended personal

. protective equipment.

Close contact can include caring for, living with, visiting, or sharing a healthcare waiting area or room with a confirmedcase.

The epidemiological link may have occurred within a 14-day period before orafter the onset of illness in the case under consideration.

C. Patient Screening

The objective of screening is to quickly identify people with a travel history tocountries with ongoing transmission of 2019-nCoV ARD. All personnel in healthfacilities should be trained on the following 2019-nCoV ARD screening procedures:

1.

2.

we

ns

Screen at all points of entry to the health facility (to catch every patient andvisitor).Use broadcriteria to quickly identify all patientsat risk (i.e. travel to China inthe last 14 days).Train screening staff on what to probe. e.g., Have you traveled overseas in thelast 14 days? Did you travel to China? Have you visited any animal or seafoodmarket? Did you visit any healthcare facility or sick person during your travel?Train screening staff on what to do once a PUI is identified.Identify holding and isolation areas and healthcare workers who will performfurther assessmentof patients.Ensure that effective triage checklist and patient flow arein place.Ensure that necessary precautions are observed:a) Designate a well-ventilated area.b) Maintain a minimum |-meter distance from patients.c) Provide symptomatic patients with facemask for source control when

possible.3

d) Perform hand hygiene frequently.e) Follow standard precautions and droplet precautions when evaluating

patients with acute respiratory tract infections.Once identified, immediately isolate PUIs in designated holding or isolationareas with full infection control precautions.There should be prompt reporting of cases to surveillance units for immediatecontact tracing and quarantine measures. Ensure that the relevant contactnumbers are readily available.

D. Patient Triage

The objective oftriage is to determineif patients have symptoms of 2019-nCoV ARDinfection and if so, to promptly isolate them. Only health care personnel shouldperform triage.

1.

2.

Triage should ideally be conducted in an isolation room with negative pressureand/or adequate ventilation.Other respiratory hygiene supplies (such as facial tissues), trash cans, and handhygienefacilities should be available inside the room.Triage officers should wear the appropriate PPE.Triage officers shall conduct a complete history and physical examination, anddecide whether a patient fulfills the case definition or criteria for the specific-Respiratory Infection of Pandemic or Outbreak Potential (RIPOP) inconsultation with surveillance officers and consultant(s) in charge of EREIDs.If patients are in queue (surge of patients), separate the “sick” from the “well”patients by 6 feet (2 meters) , and ensure patients are at least 3 feet (1 meter)apart from each other.

E. Referral for Admission

1.

2.

Symptomatic contacts or PUIs should be considered for admission for closeobservation in a health facility.Based on WHOguidelines, coordination with a health facility and/or health careprovider should be done during the observation period. Medical personnelshould be involved in reviewing the current health status of the contacts byphone and, ideally, by scheduled visits on a regular (e.g. daily) basis,performing specific diagnostic tests as necessary.Doctors and other health care professionals should give advance instructions onwhere to seek care when a contact becomes ill, what should be the mostappropriate mode of transportation, when and where to enter the designatedhealth care facility, and what infection control precautions should be followed.Once the receiving medical facility has been notified that a symptomaticcontact will be referred to their facility, the facility should facilitate transport ofpatientto the facility.Theill contact should be advised to perform respiratory hygiene and standorsitas far away from others as possible or at least 3 feet (1 meter), when in transitand when in the health care facility.Appropriate hand hygiene should be employed bythe ill contact and caregivers.Any surfaces that become soiled with respiratory secretions or body fluidsduring transport should be cleaned with regular household cleaners or a dilutedbleach solution, whichever is most appropriate.

F. Isolation Precautions

1. The duration of infectivity for 2019-nCoV ARD is unknown. While StandardPrecautions should continue to be applied always, additional isolationprecautions should be used during the duration of symptomatic illness andcontinued for 24 hoursafter the resolution of symptoms. (Annex A2)Given that little information is currently available on viral shedding and thepotential for transmission of 2019-nCoV ARD, testing for viral shedding shouldassist the decision making whenreadily available.Patient information (e.g. age, immune status and medication) should also beconsidered in situations where there is concern that a patient may be sheddingthe virus for a prolonged period.

G.,Notification

1. Designated disease surveillance officers in hospitals and other facilities shall beresponsible for doing the preliminary assessment of suspected cases in theirrespective health facility and report accordingly using the form in Annex D.Healthcare providers should immediately notify the infection control personnelat their healthcare facility and report any eventof a possible case of 2019-nCoVARD to the Municipal Health Officer (MHO)or City Health Officer (CHO) forverification and initial investigation. The MHO/CHOshall then report to theRegional Epidemiology Surveillance Unit (RESU) using the Event-BasedSurveillance System (ESR) system of the Epidemiology Bureau (EB) of DOH.

H. Clinical Management

1. There is no current evidence from RCTs to recommend any specificanti-2019-nCoV ARD treatment for PUIs or confirmed cases.

2. All healthcare providers are advised to use the latest available clinical practiceguidelines issued by local specialty societies and duly-endorsed by the DOH.Inthe interim, a separate issuance will be published by the DOH.

I. Discharge and Follow-up

Due to the evolving nature of the etiology of 2019-nCOV, guidance for dischargecriteria and management during follow-up shall be regularly updated and publishedin aseparate issuance. In the interim, the following shall apply.

1. Confirmed positive cases on admission SHOULD ONLY be discharged if ALLof the following conditions are fulfilled:

a. Two negative RT-PCRtests for 2019-nCoV ARD done 48 hoursapart.b. Afebrile and asymptomatic (including cough and respiratory symptoms)

for 48 hours.c. Laboratory and radiologic tests done according to clinical case

management(e.g. chest x-ray WBC, platelet count, CPK, liver functionstests, plasma sodium) previously abnormal returning to normal

PUIs admitted as per DOH Decision Tool (4nnex C), shall be discharged uponNEGATIVE 2019-nCoV ARD test from RITM. Until then PUIs shall beadmitted in isolation even if asymptomatic. Repeat testing for patients with aninitial negative nCoV test result may be performed if a high index for suspicion

5-

for 20191-nCoV ARD remains. despite an initial negative test result. Suchconditions include, but are not limited, to the following:

a. Clinical deterioration in the presence of an established disease etiologyand with adequate treatment. A single negative test result, particularlyif this is from an upper respiratory tract specimen, does not excludeinfection. Repeat sampling and testing, preferably of lower respiratoryspecimen, is strongly recommended in severe or progressive disease.Consider a possible co-infection with 2019-nCoV.

. No other etiology for the patient's signs and symptoms has beenidentified despite work-up.Clinical specimen(s) initially sent was/were deemed to beunsatisfactory or insufficient (delay in transport and processing, only

NPSor OPS was sent).

3. For mortalities of 2019-nCoV ARD, refer to guidelines for Disposal andShipmentof the Remains of confirmed cases of 2019-nCoV ARD.

4. Hospital Disease Surveillance Officer shall report to the RESU within 24 hoursthe patients that have been discharged. The RESU shall then report to the DOHRegional Director and the 2019-nCoV ARD Task Force

a. One week after discharge, confirmed cases should submit to mandatoryfollow-up and retesting for chest x-ray, complete blood count, and otherlaboratory tests which previously yielded abnormalresults.

H. Sources of 2019-nCoV ARD Information and Advisories

1.

2.

Everyone is advised to refrain from sharing unverified reports and/or false news.to avoid undue stress and worry due to misinformation.For announcements and public advisories, you mayvisit the following officialDOH channels:

@ Website: https://www.doh.gov.ph/2019-nCoVe Facebook: https://www.facebook.com/OfficialDOHgov/e Twitter:_https://twitter.com/DOHgov

DOH health promotion materials (e.g. infographics, social media cards amongothers) may be reproduced by hospitals and other health facilities forinstructional use or to keep health workers and patients informed free of charge.

Forstrict compliance of all concerned.

Secretary of Health

AnnexA.Infection Prevention and Control Practices

1. HAND HYGIENEa. Proper handwashing is the single most effective way to prevent infections in the

hospital.b. Hand hygiene practices in the health facility must be emphasized using the

WHO Multimodal Hand Hygiene Strategy: 5 Moments of Hand Hygiene(Annex A1) and proper handwashing technique.

c. The availability of alcohol-based hand rubsat point-of-care and other areas ofthe facility must be ensured.

2. ISOLATION PRECAUTIONTo achieve effective interruption in the transmission of an infectious agent, it isessential to use twotiers of precautions (Annex A2)

a. Standard Precautions for the care ofall patients; ANDb. Transmission-based precautions for patients with known or suspected disease

spread by any of these routes: Airborne Precautions, Droplet Precautions orContact Precautions

3. PERSONAL PROTECTIVE EQUIPMENTa. Appropriately wearing personal’ protective equipment (PPE), such as gloves,

masks, and gowns,is also essential to protect healthcare workers from contactwith infectious agents. The selection of PPE is based on the nature ofthe patientinteraction and/or mode oftransmission (Annex A3).

b. Hand hygiene is always the first and the final step before wearing or afterremoving and disposing of PPE.

4. DECONTAMINATION, DISINFECTION AND STERILIZATIONProper cleaning, disinfection and sterilization is one of the most effective ways ofdisrupting the transmission and spread of microorganisms in thehealthcare setting.Existing protocols need to be strictly implemented by healthcare personnel (Annex A4).

5. SPECIMEN COLLECTIONa. All specimens collected for laboratory testing shall be regarded as potentially

infectious..

b. All Health Care Workers who will collect, handle or transport, perform testingany clinical specimens shall adhere rigorously to the standard precautionmeasures such as Personal Protective Equipment(i.c. gloves, laboratory gown,N95 Masks, face shield, etc.), and ensure biosafety practices are observed tominimize the possibility of exposure to pathogens.

c. For further details of the guidelines kindly refer to the “Interim LaboratoryBiosafety Guidelines for Handling and Processing Suspected 2019 NovelCoronavirus (2019 nCoV) Specimens” of Research Institute for TropicalMedicine.

6. SPECIMEN HANDLING, PROCESSING, PACKAGING AND TRANSPORTTo ensure that proper handling, processing, packaging and transport of laboratoryspecimens from suspected Person UnderInvestigation (PUI) is observed, please refer tothe DOH Manual on Packaging and Transport of Laboratory Specimen for Referral andInterim Laboratory Biosafety Guidelines for Handling and Processing Suspected2019-nCoV Specimens (http://bit.ly/2tdLr4x)

7, FLOW OF PATIENTS SUSPECTED TO BE INFECTIOUSEarly detection and placement of patients to appropriate areas in the health facility iscritical in the prevention of spread of infectious diseases, For guidelines on themanagement of patients suspected to be infectious, kindly refer to the InterimGuidelines on the Preparedness and Response to Novel Coronavirus (2019-nCoV)issued,

Health facilities should ensure that all resources and contingencies needed to supportthe management of patients and for the implementation of infection prevention andcontrol measures are adequately available.

8. DISPOSAL OF INFECTIOUS BODYForproper handling of infectious body, strict adherence to precautionary measures is amust. Kindly refer to the Guidelines on Disposal of Dead Persons from DangerousCommunicable Diseases for guidance.

9, HEALTHCARE WASTE MANAGEMENTa. “Health Care Waste” (HCW) includes all the solid and liquid waste generated as

a result of any of the following: (Annex A5)i. Diagnosis, treatment, or immunization of human beings;

ii. Research pertaining to the above activities;iti. Research using laboratory animals for the improvement of human

health;iv. Production ortesting of biological products; andv. Other activities performed by health care facilities.

b. Management of health care waste, more specifically of the hazardous wastetypes (which include infectious waste) must be done through proper’ wastedisposal to mitigate risks and potential health hazards to people exposed.Infectious waste should always be assumed to potentially contain a variety ofpathogenic microorganisms that may enter the human body through thefollowing routes:

i. through a puncture, abrasion, or cut in the skinii, through the mucous membrane

iii. by inhalationiv. by ingestion

10. REFERENCESFull WHO guidelines are available at Infection prevention and control of epidemic-and pandemic-prone acute respiratory infections in health care. Retrieved from the

following:

rus-(2019-ncov)-outbreak

Annex Al. Five Moments of Handwashing

Source:The patient zone, health-care area, and critical sites with inserted time-space representation of“My five moments for hand hygiene” (Figure J.21.5b). Reprinted by the World HealthOrganization from Sax, 2007 with permission from Elsevier. Retrieved from

y s.who.int/iris/bitstrearn/handle/10665/44 41597906eng.pdf-jsessionid=F'58881D16DB6861F4F387CED85E3A 998?sequence=1

Annex A2. Isolation Precautions

A. Standard Precautions1. Standard precautions are recommended for all hospitalized patients should consist

of hand hygiene and respiratory hygiene with cough etiquettes. This also includes

safe disposalof instruments andsoiled linens.2. All healthcare workers should use appropriate barrier precautions to avoid skin and

mucous membrane exposure when contact with blood or body fluids from anypatient.

3. Gloves should be worn for contact with blood and body fluids, mucous membranes,

or non-intact skin; when handling surfaces or items soiled with blood or bodyfluids; or for venipuncture or other procedures involving vascular access.

4. Gloves should be changed after each patient contact.5. Masks and protective eyewear or face shields should be worn when procedures are

likely to generate aerosols or droplets of blood or other bodyfluids.6. Gowns should be worn for procedures thatare likely to soil clothing.7. Hands or skin contaminated with blood or body fluids should be washed

immediately using soap and water. Hand hygiene should be done after removing

gloves.8. Precautions should be. taken to prevent sharps or needlestick injuries. Needles

should not be recapped, removed from disposable syringes, or manipulated by hand.

After use, needles, disposable syringes, scalpels, and other disposable sharpinstruments should immediately be placed in a designated puncture-resistantcontainer.

9. Mouthpieces and resuscitation devices should be readily available for use in areaswhere resuscitation procedures may be anticipated.

10. All healthcare workers with exudative skin lesions should not be involvedin direct

patient care or should not handle patient-care equipment until the condition hasresolved.

Transmission-based Precautions1. When standard precautions are not able to completely interrupt the route of

transmission of certain infections, transmission-based precautions are implemented.

Contact Precautions1. Contact Precautions are intended to prevent transmission of pathogens which are

spread by direct or indirect contact with the patient or the patient’s environment.Itapplies when there is presence of excessive wound drainage, fecal incontinence, orother discharges from the body suggest an increased potential for extensiveenvironmental contamination andrisk of transmission.

2. A single-patient roomis preferred for patients who require Contact Precautions.When a single-patient room is not available, consultation with the ICC isrecommended to assess the various risks associated with other patient placementoptions (e.g., cohorting, keeping the patient with an existing roommate).

4, In multi-patient rooms, 23 feet spatial separation between beds is advised to reducethe opportunities for inadvertent sharing of items between the infected/colonized

patient andotherpatients.5, Healthcare personnel caring for patients on Contact Precautions MUST wear a

gown and gloves for all interactions that may involve contact with the patient orpotentially contaminated areasin the patient’s environment.

»

6. Donning PPE upon room entry and discarding before exiting the patient room isdone to contain pathogens, especially those that have been implicated intransmission through environmental contamination.

D. Droplet Precautions1.

te

Droplet Precautions are intended to prevent transmission of pathogens spreadthrough close respiratory or mucous membrane contact with respiratory secretions.Because these pathogens do not remain infectious over long distances in ahealthcare facility, special air handling and ventilation are not required to preventdroplet transmission.A single patient room is preferred for patients who require Droplet Precautions.When a single-patient room is not available, consultation with the ICC isrecommended,Spatial separation of >3 feet and drawing the curtain between patient beds isespecially important for patients in multi-bed rooms with infections transmitted bythe droplet route.

. Healthcare personnel caring for patients on Droplet Precautions MUST wear a mask(a respirator is not necessary) for close contact with infectious patient; the mask isgenerally donned upon room entry.Patients on Droplet Precautions who mustbe transported outside of the room should "

wear a maskif tolerated and follow Respiratory Hygiene and Cough etiquette.

E. Airborne Precautions1. Airborne Precautions prevent transmission of. infectious agents that remain

infectious over long distances when suspended in the air (ie. rubeola virus{measles], varicella virus [chickenpox], M. tuberculosis, and SARS-CoV).The preferred placement for patients who require Airbome Precautions is in anairborne infection isolation room (ATIR).

. An ATIR is a single-patient room that is equipped with special air handling andventilation capacity that meet international standards (i.c., monitored negativepressure relative to the surrounding area, 12 air exchanges per hour for newconstruction and renovation and 6 air exchanges per hour for existing facilities, airexhausted directly to the outside or recirculated through HEPA filtration beforereturn)It is best that isolation rooms are present in hospitals, emergency departments, andnursing homesthat care for patients with M. tuberculosis.In settings where Airborne Precautions cannot be implemented due to limitedengineering resources (e.g., physician offices), masking the patient, placing thepatient in a private room (e.g., office examination room) with the door closed, andproviding N95 or higher level respirators or masks if respirators are not availablefor healthcare personnel will reduce the likelihood of airborne transmission until thepatient is either transferred to a facility with an AIIR or retumed to the homeenvironment, as deemed medically appropriate.Healthcare personnel caring for patients on Airborne Precautions MUST wear amask or respirator, depending on the disease-specific recommendations that isdonned prior to room entry.

Annex A3. Personal Protective Equipment (PPE)

A. Gloves1,

~°

Gloves are used to prevent contamination of healthcare personnel hands when:a) anticipating direct contact with blood or body fluids, mucous membranes,

non-intact skin and other potentially infectious materialb) having direct contact with patients who are colonized or infected with

pathogens transmitted by the contact routec) handling or touching visibly or potentially contaminated patient care

equipment and environmental surfaces,The healthcare personnel should use the following during specimen collection on aPUI: Double Gloves (preferably: Nitrile); Scrub suit; Disposable Laboratory Gown(impermeable/ breathable/ long sleeves/ back enclosure) ; Fit Tested N95 mask;Face shield / visor.

. During patient care, transmission of infectious organisms can be reduced byadhering to the principles of working from “clean” to “dirty” and confining orlimiting contamination to surfaces that are directly neededfor patient care.It may be necessary to change gloves during the care of a single patient to preventcross-contamination of body sites.

It also may be necessary to change gloves if the patient interaction also involvestouching portable computer keyboards or other mobile equipment that is transportedfrom room to room.Discarding gloves between patients is necessary to prevent transmission ofinfectious material.Gloves must not be washed for subsequent reuse because microorganisms cannot beremoved reliably from glove surfaces and continued glove integrity cannot beensured.Whengloves are worn in combination with other PPE, they are put on last.Hand hygiene following glove removal further ensures that the hands will not carrypotentially infectious material that might have penetrated through unrecognizedtears or that could contaminate the hands during glove removal.

B. Isolation GownsL. Isolation gowns are used as specified by Standard and Transmission-Based

Precautions to protect the HCW’s arms and exposed body areas; and to preventcontamination of clothing with blood, body fluids, and other potentially infectiousmaterial.When applying Standard Precautions, an isolation gown is worn only if contact withblood or bodyfluid is anticipated.

. When Contact Precautions are indicated, donning of both gown and gloves uponroom entry is indicated to address unintentional contact with contaminatedenvironmental surfaces.Gownsare usually the first piece of PPE to be donned. Full coverage of the armsand body front, from neck to the mid-thigh or below will ensure that clothing andexposed upper body areasare protected.Isolation gowns should be removed before leaving the patient care area to preventpossible contamination of the environment outside the patient’s room.Isolation gowns should be removed in a manner that prevents contamination ofclothing or skin. The outer, “contaminated” side of the gown is turned inward androlled into a bundle, and then discarded into a designated container for waste orlinen to contain contamination.

C. Face Protection

a. Face Masks1. Masks are used for three primary purposes:

a. Placed on HCWsto protect them from contact with infectiousmaterial from patients, example, respiratory secretions andsprays of blood or body fluids, consistent with StandardPrecautions and Droplet Precautions;

b. Placed on HCWs when engaged in procedures requiringsteriletechnique to protect patients from exposure to infectious agentscarried in a HCW’s mouth or nose;

c. Placed on coughing patients to limit potential dissemination ofinfectious respiratory secretions from the patient to others(Respiratory Hygiene/Cough Etiquette).

2. Masks may be used in combination with goggles to protect the mouth,nose and eyes, or a face shield may be used instead of a mask andgoggles, to provide a more complete protection for the face

b. Goggles1. The eye protection chosen for specific work situations depends upon the

circumstances of exposure, other PPE used, and personal vision needs.2. Personal eyeglasses and contact lenses are NOT considered adequate eye

protection.3. Even if Droplet Precautions are not recommended for a specific

respiratory tract pathogen, protection for the eyes, nose and mouth byusing a mask and goggles, or face shield alone, is necessary whenit islikely that there will be a splash or spray of any respiratory secretions orother body fluids.

Annex A4. Decontamination, Disinfection and Sterilization

A. Decontamination and Disinfection Practices

The following must be observed in the decontamination and disinfection practices:1.

2.

3.

Use appropriate hand hygiene, PPE (e.g., gloves), and isolation precautions duringcleaning and disinfecting procedures.Have clear instructions and provide feedback to the personnel on how to properlywear PPE appropriate for a surface decontamination and cleaning task.Discard used PPE by using routine disposal procedures or decontaminate reusablePPEas appropriate.Use standard cleaning and disinfection protocols to control environmentalcontamination.Pay close attention to cleaning and disinfection of high-touch surfaces inpatient-care areas (e.g., bed rails, carts, charts, bedside commodes, bed rails,doorknobs,or faucet handles)Ensure compliance by housekeeping staff with cleaning and disinfection proceduresby putting up checklists.When contact precautions are indicated for patient care, use disposable patient-careitems wherever possible to minimize cross-contamination with multiple-resistantmicroorganisms.

B. Spaulding Classification for Disinfection & Sterilization of Healthcare Items

CLASSIFICATION ITEM USE GOAL APPROPRIATEPROCESS

Critical Items Items entering sterile|Objects will be Sterilization (or usetissue, the body sterile (free ofall of single use sterilecavity, the vascular microorganisms product)system and non including bacterial|© Steam sterilizationintact mucous spores) © Low temperaturemembranes,e.g. methods (ethylenesurgical instruments oxide, peracetic

acid, hydrogenperoxide plasma)

Semi-critical Items Items that make Objects will be free|High levelcontact, directly of all disinfectionor indirectly, with microorganisms, e@ Thermalintact mucous with the exception of disinfectionmembranes or high numbers of © Chemicalnon intact skin, bacterial spores disinfectione.g. endoscopes, (glutaraldehyde,diagnostic probes OPA)(vaginal/rectal),anesthetic *It is alwaysequipment preferable to

sterilizesemi-critical items

whenever they arecompatible withavailablesterilizationprocesses

Non-critical Items Objects that come Objects will be clean|Low levelinto.contact with disinfectionintact skin but not e Cleaningmucous membranes, (manual ore.g. crutches, BP mechanical)cuffs

Annex A5. Healthcare Waste

A. Healthcare Waste TypesHealthcare waste (HCW) can be broadly categorized into “hazardous” and“non-hazardous” waste types, as listed below.

:

HAZARDOUS NON-HAZARDOUS (General)

- Sharps - Recyclable- Infectious - Biodegradable- Pathological - Residual- Anatomical- Pharmaceutical- Genotoxic- Chemical- Radioactive- Pressurized Containers

Hazardous HCW, which includes infectious wastes, refers to waste that may pose avariety of environmental and health risks. Infectious waste is most likely to containpathogens (bacteria, viruses, parasites, or fungi) in sufficient concentration or quantityto cause disease in susceptible hosts.

B. Risks Associated with Health Care Waste1. All individuals coming into proximity with hazardous HCW are potentially atrisk,

including those who generate hazardous HCW,as well as those whoeither handlesuch waste or are exposed to it as a consequence of improper management.

2. The main groups of peopleat risk to potential health hazards associated with HCWare the following:

HCFstaff, e.g., doctors, nurses, auxiliaries, and maintenance personnelPatients in the HCF or receiving home careVisitors to the HCFWorkers providing support and allied services to the HCF, such as laundryWorkers transporting hazardous HCW to treatment, storage, and disposalfacilities :

Workers and operators of waste management facilities (e.g., sanitary landfilland Treatment, Storage, Disposal (TSD) facilities) including informalrecyclers or scavenger.

3, The General Public could also be at risk whenever hazardous HCW is abandoned ordisposed of improperly.

eae

oP

rh

C. Health Care Waste Disposal1. HCW that is properly treated with the applicable technology as stated in the Health

Care Waste Management Manual can be disposed of in a sanitary landfill but mustnot be mixed with the municipal waste. Dedicated cells for the treated HCW mustbe provided in a sanitary landfill. To allow the disposal of HCW to the sanitarylandfill, the following must be met:

a. The waste treatment facility/system passed the standards for microbialinactivation test;

b. The properly treated HCW passed the sporestrip test;

10

c. The waste treatmentfacility/system has a valid CPR from the DOH-Bureauof Health ‘Devices and Technology (BHDT), and;

d. The waste treatment facility is an EMB-registered TSD facility.

11

Annex B. Clinical Managementof Severe Acute Respiratory Infection when Novel Coronavirus (2019-nCoV)Infection is Suspected (Interim guidance as ofJanuary 28, 2020)

“Clinigak‘managementof severe acute:respiratoryinfection whennovel.coronavirus.(2019-nCoV) o“infection: ssuspectedInterim guidance

WHoincovictnicaraczo, a

Introduction

This is the first edition of this document for novel coronavirus, an adaption of WHO Clinical management of severe acuterespiratory infection when MERS-CoV infection is suspected publication (2019).

This document is intended forclinicians taking care of hospitalised adult and paediatric patients with severe acute respiratoryinfection (SARI) when 2019-nCoVinfection is suspected. It is not meant to replace clinical judgmentor specialist consultationbut ratherto strengthen clinical managementof these patients and provide to up-to-date guidance, Best practices for SARIincluding IPC and optimized supportive care for severelyill patients are essential.

This document is organized into the following sections:Triage: recognize and sort patients with SARIImmediate implementation of appropriate infection prevention and control (IPC) measuresEarly supportive therapy and monitoringCollection of specimens for laboratory diagnosisManagementof hypoxemic respiratory failure and acute respiratory distress syndrome (ARDS)Managementof septic shockPrevention of complicationsSpecific anti-nCoV treatmentsSpecial considerations for pregnant patients

PRON

AMWAPYD

DO

These symbols are used to flag interventions:

@ Do: the intervention is beneficial (strong recommendation) ORthe intervention is a best practice statement

€=Don’t: the intervention is known to be harmful.@% Consider: the intervention may be beneficial in selected patients (conditional recommendation) ORbe careful whenconsidering this intervention.

This document aims to provide clinicians with updated interim guidance ontimely, effective, and safe supportive management ofpatients with 2019-nCoV and SARI, particularly those with critical illness.

The recommendationsin this document are derived from WHO publications.!+ Where WHO guidanceis not available, we refer toevidence-based guidelines, Members of a WHO global network of clinicians, and clinicians who have treated SARS, MERSorsevere influenza patients have reviewed the recommendations (see Acknowledgements). For queries, please email outbreak@who.int

with ‘2019-nCoVclinical question’ in the subjectline.

Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCaV) infection is suspected: Interim Guidance

1. Triage: early recognition of patients with SARI associated with 2019-nCoVinfection@ Triage: recognize and sort all patients with SARIat first point of contact with health care system (such as the emergencydepartment}. Consider 2019-nCOV as a possible etiology of SARI under certain conditions (see Table 1). Triage patients and startemergency treatments based based on disease severity.

Remarks: 2019-nCoVinfection may present with mild, moderate, or severe illness; the latter includes severe pneumonia, ARDS,sepsis and septic shock. Early recognition of suspected patients allows for timely initiation of IPC (see Table 2). Earlyidentification of those with severe manifestations (see Table 2) allows for immediate optimized supportive care treatmentsandsafe, rapid admission (or referral) to intensive care unit according to institutional or national protocols. For those withmild illness, hospitalization may not be required unless there is concern for rapid deterioration. All patients discharged homeshould be instructed to return to hospital if they develop any worsening of illness.

Table 1. Definitions of patients with SARI, suspected of 2019-nCoV infection*

SARI An ARI with history of fever or measured temperature 238 C° and cough; onset within the last ~10 days; and requiringhospitalization.5 However, the absence of fever does NOT exclude viral Infection.’

SorTeans A. Patients with severe acute respiratory infection {fever, cough, and requiring admission to hospital), AND with no other

for 2019-nCoV* etiology that fully explains the clinical presentation’ AND at least one of the follawing:

© ahistory of travel to or residence in the city of Wuhan, Hubei Province, China in the 14 days prior to symptom onset,or

patient is a health care worker who has been working In an environment where severe acute respiratory Infections ofunknown etiology are being cared for.

B, Patients with any acute respiratory illness AND atleastone of the following:

close contact? with a confirmed or probable case of 2019-nCoVin the 14 days prior to illness onset, ore visiting or working in a live animal market in Wuhan, Hubel Province, China in the 14 days prior to symptom onset,

or¢ worked or attended a health care facility in the 14 days prior to onsetof symptoms where patients with hospital

associated 2019-nCov infections have been reported.

“See httos/Avww who. inthealth-topics/coronavirus for latest case definitions1 clinicians should also be alert to the possibility of atypical presentations in patients who are immunocompromised;2; Close contact’ is defined as:

= Health care associated exposure, including providing direct care for nCoV patients, working with health care workers Infected with novel coronavirus,visiting patients or stayingin the same close environmentas a nCoVpatient.

- Working togetherin close proximity or sharing the same classroom environmentwith a nCoV patient= Traveling togetherwith a nCoV patient in any kind of conveyance= Livingin the same household as a nCoV patlent

The epidemiological link may have occurred within a 14-day period from onsetof illness in the case under consideration.

Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV) infection is suspected: Interim Guidance

Table 2. Clinical syndromes associated with 2019-nCoV infectionUncomplicatediIness

Mild pneumonia

Severepneumonia

AcuteRespiratoryDistressSyndrome"?

Sepsis'®"1

Septicshock'®2

Patients with uncomplicated upper respiratory tract viral infection, may have non-specific symptoms such as fever, cough, sorethroat, nasal congestion, malaise, headache, muscle pain or malaise. The elderly and immunosuppressed may present withatypical symptoms. These patients do not have any signs of dehydration, sepsis or shortness of breath.

Patient with pneumonia and no signs of severe pneumonia.Child with non-severe pneumonia has coughordifficulty breathing + fast breathing: fast breathing (in breaths/min): <2 months,260; 2-11 months, 250; 1-5 years, 240 arid no signs of severe pneumonia.

Adolescent or adult: fever or suspected respiratory infectlon, plus one of respiratory rate >30 breaths/min, severe respiratorydistress, or SpOz <90% on room air (adapted from [']).Child with coughor difficulty in breathing, plus at least oneof the following: central cyanosis or SpO2<90%; severe respiratorydistsess (€.9. grunting, very severe chest indrawing); signs of pneumonia with a general danger sign: inability to breastfeed ordrink, lethargy or unconsciousness, or convulsions. Other signs of pneumonia may be present: chest indrawing, fast breathing Gn

breaths/min): <2 months, 260; 2-11 months, 250; 1-5 years, 240.2 The diagnosis is clinical; chest imaging can excludecomplications,

Onset: new or worsening respiratory symptoms within one week of known clinical insult.Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully explained by effusions, lobaror lungcollapse, or nodules,Origin of oedema: respiratory failure not fully explained by cardiac failure orfluld overload. Need objective assessment (2.9.echocardiography) to exclude hydrostatic cause of oedema if no risk factor present.Oxygenation (adults):

«—Mild ARDS: 200 mmHg < PaO2/FiO2 < 300 mmHg (with PEEP or CPAP 25 cmH20,’ or non-ventilated®}

« Moderate ARDS: 100 mmHg < PaOzFi02 $200 mmHg with PEEP 25 cmH,0,’or non-ventilated®)¢ Severe ARDS: PaO2/FiO2 s 100 mmHg with PEEP 25 cmH20,’ or non-ventllated®)e@ When PaOzis not available, SpO2/FIO2 $315 suggests ARDS {including in non-ventilated patients)

Oxygenation (children; note Ol = Oxygenation Index and OSI= Oxygenation Index using Sp0:);¢—Bilevel NIV or CPAP 25 cmH:0viafull face mask: PaQ2/FiO2 s 300 mmHg or SpO2/FiO2 $264¢ Mid ARDS (invasively ventilated): 4 < O1 <8 or 5S 0S1< 7.5

* Moderate ARDS (invasively ventilated): 8 s Ol < 16 or 7.5 s OS} < 12.3

«—Severe ARDS {invasively ventilated): O1 2 16 or OSI 2 12.3

Adults: fifethreatening organ dysfunction caused by a dysregulated host response to suspected or proven infection, with organdysfunction’. Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low oxygen saturation, reducedurine output, fast heart rate, weak pulse, cold extremities or fow blood pressure, skin mottling, or laboratory evidence ofcoagulopathy, thrombocytopenia, acidosis, high lactate or hyperbllirubinemia.Children; suspectedor proven infection and 22 SIRS criteria, of which one must be abnormal temperature or white blood cellcount.

Adults: persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP 265 mmHg and serumJactate level >2 mmoVL.

Chikiren (based on ['2]): any hypotension (SBP <5" centlle or >2 SD befow normal for age) or 2-3 of the following: atered mentalstate; tachycardia or bradycardia (HR <90 bpm or >160 bpm in infants and HR <70 bpm or >150 bpm in children); prolongedcapillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea; mottled skin or petechial or purpuric rash; increasedlactate: oliguria; hyperthermia or hypothermia.

‘Abbreviations: ARI, acute respiratory infection; BP, blood pressure; bpm, beats/minute; CPAP, continuous positive alrway pressure; Fiz, fraction of inspired oxygen; MAP, meanartarial pressure; NIV, noninvasive ventitation; Ot, Oxygenation Index; OS!, Oxygenation Index using SpOz; PaQz, partial pressure of oxygen; PEEP, positive end-expiratory

pressure; SBP, systolic blood pressure; SD, standard deviation; SIRS, systemic Inflammatory response syndrome; SpOz, oxygen saturation. “If attitude Is higher than 1000m, thencorrection factor should be calculated as follows: PaO2FiO2x Barometric pressure/760.

* The SOFAscore ranges from 0 ta 24 and Inchides points relaied to 6 organ systems: respiratory (hypoxemia defined by low PaO,/Fi0;}, coagulation (low platelets), Svar (highbilirubin}, cardiovascular (hypotension), central nervous system (low level of consciousness defined by Glasgow Coma Scale), and renal (low urine output or high creatinine).

Sepsis is defined by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score’ of 22 points, Assume the baseline score 's zero if data are notavailable

Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV) infection is suspected: Interim Guidance

2. Immediate implementation of appropriate IPC measuresIPC isacritical and integral part of clinical management ofpatients and should be initiated at the point of entry of the patient tohospital (typically the Emergency Department). Standard precautions should alwaysbe routinely applied in all areas of health carefacilities. Standard precautions include hand hygiene; use of PPE to avoid direct contact with patients’ blood, body fluids,secretions (including respiratory secretions) and non-intact skin. Standard precautions also include prevention of needle-stick orsharps injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment.

Table 2. How to implement infection prevention and control measures for patients with suspected or confirmed 2019-nCoV infection4445

At triage Give suspect patient a medical mask and direct patient to separate area, an isolation room if available. Keep at least {meterdistance between suspecied patients and other patients. Instruct all patients to cover nose and mouth during coughing orsneezing with tissue or flexed elbow for others. Perform hand hygiene after contact with respiratory secretions

Apply droplet precautions Droplet precautions prevent large droplet transmissionof respiratory viruses, Use a medical maskif working within 1-2 metre sof the patient. Place patients In single roms, or group together those with the same etiological diagnosis. If an etiologicaldiagnosis is not possible, group patients with similar clinical diagnosis and based on epidemiological risk factors, with a spatialseparation, When providing care in close contact with a patient with respiratory symptoms (e.g. coughing or sneezing), use eyeprotection (face-mask or goggles), because sprays of secretions may occur, Limit patient movement within the institution and

ensure that patients wear medical masks when outside their rooms.

Apply contact precautions Droplet and contact precautions preventdirector indirect transmission from contact with contaminated surfaces or equipment(.2. contact with contaminated oxygen tubing/interfaces). Use PPE (medical mask, eye protection, gloves and gown) whenentering room and remove PPE when leaving. If possible, useelther disposable or dedicated equipment (e.g. stethoscopes,blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect between eachpatient use, Ensure that health care workers refrain from touching their eyes, nose, and mouth with potentially contaminatedgloved or ungloved hands. Avoid contaminating environmental surfaces that are not directly related to patient care (e.g. doorhandles and fight switches). Ensure adequate room ventilation. Avoid movementof patients or transport. Perform handhygiene.

Apply airborne Ensure that healthcare workers performing aeroso!-generating procedures {i.6. open suctioning of respiratory tract,precautlons when intubation, bronchoscopy, cardiopulmonary resuscitation) use PPE, including gloves, long-sleeved gowns, eye protection,

performing an aerosol and fit-tested particulate respirators (N95 or equivalent, or higher levelof protection}, (The scheduled fit test should not begenerating procedure confused with user seal check before each use.) Whenever possible, use adequately ventilated single rooms when performing

aerosol-generating procedures, meaning negative pressure rooms with minimum of 12 alr changes per houror at least 180fitres/second/patient in facilities with natural ventilation, Avoid the presence of unnecessary Individuals In the room. Care for the

patient in the same type of room after mechanical ventilation commences,‘Abbreviations: ARI, acute respiratory infection; PPE, personal protective equipment

3. Early supportive therapy and monitoring

@ Give supplemental oxygen therapy immediately to patients with SARI and respiratory distress, hypoxaemia, or shock.Remarks:Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 >90% in non-pregnant adults and SpOz>92-95 % in pregnant patients.!* Children with emergency signs (obstructed or absent breathing, severe respiratory distress,central cyanosis, shock, coma or convulsions) should receive oxygen therapy during resuscitation to target SpO2 294%; otherwise,the target SpO2 is >90%.* All areas where patients with SARI are cared for should be equipped with pulse oximeters, functioningoxygen systems and disposable, single-use, oxygen-delivering interfaces (nasal cannula, simple face mask, and mask withreservoir bag). Use contact precautions when handling contaminated oxygen interfaces of patients with nCoV infection.

@ Use conservative fluid managementin patients with SARI when there is no evidence of shock.Remarks: Patients with SARI should be treated cautiously with intravenous fluids, because aggressive fluid resuscitation mayworsen oxygenation, especially in settings where there is limited availability of mechanical ventilation.!¢

@ Give empiric antimicrobials to treatall likely pathogens causing SARI, Give antimicrobials within one hour of initial pattentassessment for patients with sepsis.

Remarks: Although the patient may be suspected to have nCoV, administer appropriate empiric antimicrobials within ONE hourof identification of sepsis.'’ Empiric antibiotic treatment should be based on the clinical diagnosis (community-acquiredpneumonia, health care-associated pneumonis [if infection was acquired in healthcare setting], or sepsis), local epidemiology andsusceptibility data, and treatment guidelines. Empiric therapy includes a neuraminidase inhibitor for treatment of influenza whenthere is local circulation or other risk factors, including travel history or exposure to animal influenza viruses.'® Empiric therapyshould be de-escalated on the basis of microbiology results and clinical judgment.

€3 Do not routinely give systemic corticosteroids fortreatmentof viral pneumonia or ARDS outside of clinical trials untess they areindicated for another reason,Remarks: A systematic review of observational studies of corticosteroids administered to patients with SARS reported no survivalbenefit and possible harms (avascular necrosis, psychosis, diabetes, and delayed viral clearance).’? A systematic review ofobservationalstudies in influenza founda higherrisk of mortality and secondary infections with corticosteroids; the evidence wasjudged as very low to low quality due to confounding by indication.” A subsequent study that addressed this limitation byadjusting for time-varying confounders found no effect on mortality.?! Finally, a recent study of patients receiving corticosteroidsfor MERS used a similar statistical approach and found no effect of corticosteroids on mortality but delayed lower respiratory

Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCaV) infection is suspected: Interim Guidance

tract (LRT) clearance of MERS-CoV.” Given lack of effectiveness and possible harm, routine corticosteroids should be avoidedunless they are indicated for another reason. See section 6 for the use of corticosteroids in sepsis.

@ Closely monitor patients with SARI for signs of clinical deterioration, such as rapidly progressive respiratory failure and sepsis,and apply supportive care interventions immediately.

Remarks: Application of timely, effective, and safe supportive therapies is the cornerstone of therapy for patients that developsevere manifestations of 2019-nCoV.

@ Understand the patient's co-morbid condition(s) to tailor the management of critical illness and appreciate the prognosis,Communicate early with patient and family.

Remarks: During intensive care management of SARI, determine which chronic therapies should be continued and whichtherapies should be stopped temporarily. Communicate proactively with patients and families and provide support and prognosticinformation. Understand the patient’s values and preferences regarding life-sustaining interventions.

4. Collection of specimensfor laboratory diagnosisWHO guidance on specimen collection, processing, and laboratory testing, including related biosafety procedures,is available.”

@ Collect blood cuttures for bacteria that cause pneumonia and sepsis, ideally before antimicrobial therapy. DO NOT delayantimicrobial therapy to collect blood cultures.

@ Collect specimens from BOTH the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) AND lower respiratory tract(LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage) for 2019-nCoV testing by RT-PCR. Clinicians mayelect to collect only LRT samples when these are readily available (for exampte, in mechanically ventilated patients).

@ Serologyfor diagnostic purposes Is recommended only when RT-PCR is not avallable,2Remarks: Use appropriate PPE for specimen collection (droplet and contact precautions for URT specimens; airbome precautionsfor LRT specimens). When collecting URT samples, use viral swabs (sterile Dacron or rayon, not cotton) and viral transportmedia. Do not sample the nostrils or tonsils. In a patient with suspected novel coronavirus, especially with pneumonia or severeillness, a single URT sample does not exclude the diagnosis, and additional URT and LRT samples are recommended.” LRT(vs.URT) samples are more likely to be positive and for a longer period.” Clinicians may elect to collect only LRT samples whenthese are readily available (for example, in mechanically ventilated patients). Sputum induction should be avoided due toincreased risk of increasing aerosol transmission.

Remarks: Dual infections with other respiratory viral infections have been found in SARS and MERScases. Atthis stage weneed detailed microbiologic studies in all suspected cases, Both URT and LRT specimens can tested for other respiratory viruses,such as influenza A and B (including zoonotic influenza A), respiratory syncytial virus, parainfluenza viruses, rhinoviruses,adenoviruses, enteroviruses (e.g. EVD68), human metapneumovirus, and endemic human coronaviruses (i.e. HKU1, OC43,NL63, and 229E). LRT specimens can also be tested for bacterial pathogens, including Legionella pneumophila.

@ In hospitalized patients with confirmed 2019-nCovV infection, repeat URT and LRT samples should be collected to demonstrateviral clearance. The frequency of specimen collection will depend on local circumstances but should beat least every 2 to 4daysuntil there are two consecutive negative results (both URT and LRT samplesif both are collected) in a clinically recoveredpatientat least 24 hours apart. If local infection control practice requires two negative results before removalof dropletprecautions, specimens maybe collected as often as daily.

5. Management of hypoxemic respiratory failure and ARDS

@ Recognize severe hypoxemic respiratory failure when a patient with respiratory distressis failing standard oxygen therapy.Remarks: Patients may continue to have increased work of breathing or hypoxemia even when oxygenis delivered via a facemask with reservoir bag (flow rates of 10-15 L/min, which is typically the minimum flow required to maintain bag inflation; FiOz0.60-0.95). Hypoxemic respiratory failure in ARDS commonly results from intrapulmonary ventilation-perfusion mismatch orshunt and usually requires mechanical ventilation.

{3 High-flow nasal oxygen (HFNO)or non-invasive ventilation (NIV) should only be used in selected patients with hypoxemicrespiratory failure, The risk of treatment failure is high in patients with MERStreated with NIV, and patients treated with eitherHFNO or NIV should be closely monitored for clinical deterioration.

Remark 1: HFNO systems can deliver 60 L/min of gas flow and FiO2 upto 1.0; paediatric circuits generally only handle up to 15

L/min, and many children will require an adult circuit to deliver adequate flow. Compared to standard oxygen therapy, HFNOreduces the need for intubation.” Patients with hypercapnia (exacerbation of obstructive lung disease, cardiogenic pulmonaryoedema), hemodynamic instability, multi-organ failure, or abnormal mental status should generally not receive HFNO, althoughemerging data suggest that HFNO maybe safe in patients with mild-moderate and non-worsening hypercapnia.” Patientsreceiving HFNO should be in a monitored setting and cared for by experienced personnel capable of endotracheal intubation incase the patient acutely deteriorates or does not improve after a short trial (about 1 hr). Evidence-based guidelines on HFNO donot exist, and reports on HFNO in MERS patients are limited.”

Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV) infection is suspected: Interim Guidance

Remark 2: NIV guidelines make no recommendation on use in hypoxemic respiratory failure (apart from cardiogenic pulmonaryoedema and post-operative respiratory failure) or pandemic viral illness (referring to studies of SARS and pandemic influenza).””Risks include delayed intubation, large tidal volumes, and injurious transpulmonary pressures. Limited data suggest a high failure

rate when MERS patients receive NIV.” Patients receivinga trial of NIV should be in 2 monitored setting and cared for byexperienced personnel capable of endotracheal intubation in case the patient acutely deteriorates or does not improve after a shorttrial (about 1 hr). Patients with hemodynamic instability, multiorgan failure, or abnormal mental status should not receive NIV.

Remark 3: Recent publications suggest that newer HFNOand NIV systems with good interfacefitting do not create widespread

dispersion of exhaled air and therefore should be associated with low risk of airborne transmission°*!

@ _Endotracheal intubation should be performed by a trained and experienced provider using airborne precautions.Remarks: Patients with ARDS, especially young children or those who are obese or pregnant, may desaturate quickly duringintubation. Pre-oxygenate with 100% FiQz for 5 minutes, via a face mask with reservoir bag, bag-valve mask, HFNO, or NIV.Rapid sequence intubation is appropriate after an airway assessment that identifies no signs ofdifficult intubation*”.

The following recommendations in this section pertain to mechanically ventilated patients with ARDS.'7? Thesefocus on adults;consensus-based recommendations for children are available*

@ Implement mechanical ventilation using tower tidal volumes (4-8 ml/kg predicted body weight, PBW) and lower inspiratorypressures (plateau pressure <30 cmH20).

Remarks: Thisis a strong recommendation fromaclinical guideline forpatients with ARDS,® andis suggested forpatients withsepsis-induced respiratory failure who do not meet ARDS criteria.'” The initial tidal volumeis 6 ml/kg PBW; tidal volumeup to 8

ml/kg PBWis allowed if undesirable side effects occur (e.g. dyssynchrony, pH <7,15). Hypercapnia is permitted if meeting thepH goal of 7.30-7.45. Ventilator protocols are available.** The use of deep sedation may be required to control respiratory driveand achievetidal volume targets. Although high driving pressure (plateau pressure-PEEP) may more accurately predict increasedmortality in ARDS compared to high tidal volumeor plateau pressure,?° RCTs of ventilation strategies that target driving pressureare not currently available.

@ In patients with severe ARDS,prone ventilation for >12 hours per day is recommended.Remarks: Application of prone ventilation is strongly recommended for adult and paediatric patients with severe ARDS* butrequires sufficient human resources and expertise to be performed safely3748

@ Use a conservative fluid management strategy for ARDS patients without tissue hypoperfusion.Remarks: This is a strong guideline recommendation;'” the main effectis to shorten the duration of ventilation. See reference [°°]

for details of a sample protocol.

€® in patients with moderate or severe ARDS, higher PEEP instead of lower PEEPis suggested.Remarks: PEEP titration requires consideration of benefits (reducing atelectrauma and improving alveolar recruitment) vs. risks(end-inspiratory overdistension leading to lung injury and higher pulmonary vascular resistance). Tables are available to guidePEEFtitration based on the FiQz required to maintain SpO2.** A related intervention of recruitment manoeuvres (RMs)isdelivered as episodic periods of high continuous positive airway pressure [30-40 cm H20], progressive incremental increases inPEEP with constant driving pressure, or high driving pressure; considerations of benefits vs. risks are similar. Higher PEEP andRMs were both conditionally recommended in a clinical practice guideline.* For PEEP, the guideline considered an individualpatient data meta-analysis” of 3 RCTs. However, a subsequent RCT of high PEEP andprolonged high-pressure RMs showedharm, suggestingthat the protocol in this RCT should be avoided.*' Monitoring ofpatients to identify those who respondto theinitial application of higher PEEPora different RM protocol, and stopping these interventions in non-responders,is suggested.”

{8 In patients with moderate-severe ARDS (PaQz/FiO2 <150), neuromuscular blockade by continuous infusion should not beroutinely used.

Remarks: Onetrial foundthat this strategy improved survival in patients with severe ARDS (PaO2/FiO2 <150) without causingsignificant weakness,” butresults of a recent larger trial found that use of neuromuscular blockage with high PEEP strategy wasnot associated with survival when comparedto a light sedation strategy without neuromuscular blockade“. Continuousneuromuscular blockade maystill be consideredin patients with ARDS in certain situations: ventilator dyssnchony despitesedation, suchthattidal volume limitation cannotbe reliably achieved; or refractory hypoxemia or hypercapnia.

4 In settings with access to expertise in extracorporeal life support (ECLS), consider referral of patients with refractory hypoxemia

despite lung protective ventilation,Remarks: A recent guideline made no recommendation about ECLSin patients with ARDS.® Since then, an RCT of ECLSforpatients with ARDS was stopped early and foundno statistically significant difference in the primary outcome of 60-day mortalitybetween ECLS and standard medical management (including prone positioning and neuromuscular blockade).“S However, ECLSwas associated with a reduced risk of the composite outcome of mortality and crossover to ECLS,* and a post hoc Bayesiananalysis ofthis RCT showed that ECLSis very likely to reduce mortality across a range of prior assumptions.*® In patients withMERS-CoV infection, ECLS vs. conventional treatment was associated with reduced mortality in a cohort study.*” ECLSshould

6

Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV) infection is suspected: Interim Guidance

only be offered in expert centres with a sufficient case volume to maintain expertise and that can apply the IPC measures requiredfor 2019-nCoV patients.”€3 Avoid disconnecting the patient from the ventilator, which results in loss of PEEP and atelectasis. Use in-line catheters for

alrway suctioning and clamp endotracheal tube when disconnection is required (for example, transfer to a transport ventilator),

6. Management of septic shock

@ Recognizeseptic shock in adults when infection is suspected or confirmed AND vasopressors are needed to maintaln meanarterial pressure (MAP) 265 mmHg AND lactate is 22 mmol/L, in absence of hypovolemia.Recognize septic shock in children with any hypotension (systolic blood pressure [SBP] <5‘ centile or >2 SD below normalforage) or 2-3 of the following: altered mental state; tachycardia or bradycardia (HR <90 bpm or >160 bpm In infants and HR <70

bpm or >150 bpm in children); prolonged capillary refill (>2 sec} or warm vasodilation with bounding pulses; tachypnea; mottledskin or petechial or purpuric rash; Increased lactate; oliguria; hyperthermia or hypothermia.

Remarks:In the absenceof a lactate measurement, use MAP and clinical signs of perfusion to define shock. Standard careincludes early recognition and the following treatments within 1 hourof recognition: antimicrobial therapy and fluid loading andvasopressors for hypotension.” The use ofcentral venous andarterial catheters should be based on resource availability andindividual patient needs. Detailed guidelines are available for the management of septic shock in adults!” and children.”

@ Inresuscitation from septic shock in adults, give at least 30 ml/kg of isotonic crystalloid in adults in the first 3 hours. Inresuscitation from septic shock in children in well-resourced settings, give 20 ml/kg as a rapid bolus and upto 40-60 ml/kgin thefirst 4 hr.

€3 Do not use hypotonic crystalioids, starches, or gelatins for resuscitation.

& Fluid resuscitation may lead to volume overload, including respiratory failure. tf there is no response tofiuid loading and signsof volume overload appear (for example, jugular venousdistension, crackles on lung auscultation, pulmonary oedema onimaging, or hepatomegaly in children), then reduce or discontinue fluid administration. This stepis particularly important wheremechanical ventilation is not available. Alternate fluid regimens are suggested whencaring for children in resource-limitedsettings

Remarks: Crystalloids include normal saline and Ringer’s lactate. Determine need for additional fluid boluses (250-1000 mlinadults or 10-20 ml/kg in children) based on clinical response and improvement of perfusion targets. Perfusion targets includeMAP (>65 mmHgor age-appropriate targets in children), urine output (>0.5 ml/kg/hr in adults, | ml/kg/hr in children), andimprovementofskin mottling, capillary refill, level of consciousness, and lactate. Consider dynamic indices of volumeresponsiveness to guide volume administration beyond initial resuscitation based on local resources and experience."? Theseindices include passive leg raises, fluid challenges with serial stroke volume measurements,or variations in systolic pressure,pulse pressure, inferior vena cava size, or stroke volumein response to changesin intrathoracic pressure during mechanicalventilation. =

Starchesare associated with an increased risk of death and acute kidney injury vs. crystalloids. The effects of gelatins are lessclear, but they are more expensive than cyrstalloids.*'? Hypotonic (vs. isotonic) solutions are less effective at increasingintravascular volume. Surviving Sepsis also suggests albumin for resuscitation when patients require substantial amounts ofcrystalloids, but this conditional recommendation is based on low-quality evidence.!”

@ Administer vasopressors when shock persists during or after fluid resuscitation. The initial blood pressure target is MAP 265mmg in adults and age-appropriate targets in children.

@_ lf central venous catheters are not available, vasopressors can be given through a peripheral lV,but use a large vein and closelymonitorfor signs of extravasation and local tissue necrosis.If extravasation occurs, stop infusion. Vasopressors can also beadministered through intraosseous needles,

gi signs of poor perfusion and cardiac dysfunction persist despite achleving MAP targetwith fluids and vasopressors, consideran inotrope such as dobutamine,

Remarks: Vasopressors (i.e. norepinephrine, epinephrine, vasopressin, and dopamine) are most safely given through a centralvenous catheterat a strictly controlledrate, butit is also possible to safely administer them via peripheral vein*? and intraosseousneedle. Monitor blood pressure frequently andtitrate the vasopressor to the minimum dose necessary to maintain perfusion andprevent side effects. Norepinephrine is considered first-line in adult patients; epinephrine or vasopressin can be added to achievethe MAP target. Because oftherisk of tachyarthythmia, reserve dopaminefor selected patients with low risk of tachyarrhythmiaor those with bradycardia. In children with cold shock (more common), epinephrine is considered first-line, while norepinephrinejs used in patients with warm shock (less common).

No RCTshave compared dobutamine to placebo for clinical outcomes.'7

Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV) infection is suspected: Interim Guidance

7. Prevention of complications

Implementthe following interventions (Table 3) to prevent complications associated with critical illness. These interventions arebased on Surviving Sepsis" or other guidelines,***” andare generally limited to feasible recommendations based on high qualityevidence.

Table 3. Prevention of complicationsAnticipated Outcome Interventions

Reduce days of invasive « Use weaning protocols that include dally assessment for readiness to breathe spontaneouslymechanical ventilation « Minimize continuous or intermittent sedation, targeting specific titration endpoints (light sedation unless

contraindicated) or with daily interruption of continuous sedative infusions

Reduce incidence of ventilators e Oral intubation is preferable to nasal intubation in adolescents and adultsassociated pneumonia Keep patient in semi-recumbent position (headof bed elevation 30-45°)

« Use aclosed suctioning system; periodically drain and discard condensate in tubing« Use anew ventilator circuit for each patient; once patient is ventilated, change circuit if it is soiled or damaged but not

routinelyChange heat molsture exchanger when it malfunctions, when soiled, or every 5-7 days

Reduce incidence of venous ¢ Use pharmacological prophylaxis (low motecular-weight heparin (preferred if available] or heparin 5000 unitsthrombeembolism subcutaneously twice dally) In adolescents and adults without contraindications. For those with contraindications, use

mechanical prophylaxis (intermittent pneumatic compression devices).

Reduce Incidence of catheter- « Use achecklist with completion verified by a real-time observer as reminder of each step needed far sterile insertionrelated blocdstream infection and as a dally reminder to remove catheterif no longer needed

Reduce incidence of pressure © Tum patient every two hoursulcers

Reduce incidenceof stress ukers © Give early enteral nutrition (within 24-48 hours of admission)and gastrointestinal bleeding Administer histamine-2 receptor blockers or proton-pump inhibitors in patients with risk factors for GI bleeding. Risk

factors for gastrointestinal bleeding include mechanical ventilation for 248 hours, coagulopathy, renal replacementtherapy, liver disease, multiple comorbidities, and higher organ fallure score

Reduce incidence of [CU-telated Actively mobilize the patient early in the course ofillness when safe to do soweakness

8. Specific anti-Novel-CoV treatments andclinical research@} There is no current evidence from RCTs to recommend any specific anti-nCoV treatment for patients with suspected or

confirmed 2019-nCovV infection.

@ Unlicensed treatments should be administered only in the context of ethically-approved clinicaltrials or the Monitored

Emergency Use of Unregistered Interventions Framework (MEUR), with strict monitoring.httos://www.who, int/ethics/publications/infectious-disease-outbreaks/en/

@ Clinical characterization protocols are available, at the WHO 2019 nCoV website:

httos:/www.who.int/emergencies/diseases/novel-coronavirus-2019. WHO hasestablished Global 2019-nCoV Clinical Data Platform, formember countrles to contribute, Contact EDCARN@wha.int for additional questions.

9. Special considerations for pregnant patients

@ Pregnant womenwith suspected or confirmed 2019-nCovV infection should be treated with supportive therapies as describedabove, taking into account the physiologic adaptations of pregnancy.

@ The useof investigational therapeutic agents outside of a research study should be guided by individual risk-benefit analysisbased on potential benefit for mother and safety to fetus, with consultation from an obstetric specialist and ethics committee,

@ Emergency delivery and pregnancy termination decisions are challenging and based on many factors: gestational age, maternal

condition, and fetal stability. Consultations with obstetric, neonatal, and intensive care specialists (depending on the conditionof the mother} are essential,

Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV)} infection is suspected: interim Guidance

10. AcknowledgementsTheoriginal version of this document was developedin consultation with Intemational Forum for Acute Care Trialists (INFACT), ISARIC and Surviving SepsisCampaign. The following individuals contributed to or reviewed the current version. Confidentiality and declarations of interest were collected and reviewed.

WHO: April Baller, Janet Diaz, Dina Pfelfer, Maria Van Kerkhove, Satoko Otsu, Richard Peabody.

Non-WHO experts: Neill Adhikari, Sunnybrook Health Sciences Centre and University of Toronto; Yaseen Arabi, King Saud Bin Abdulaziz University for Health

Sciences, Saudi Arabia; Kenneth Baillie, University of Edinburgh, UK; Gail Carson University of Oxford, ISARIC; Charles David Gomersall The Chinese

University of Hong Kong; Jake Dunning, Public Health England, UK; Rob Fowler, University of Toronto, Canada; Susan Gerber, Centers for Disease Control

and Prevention, USA; Frederick Hayden, University of Virginia, USA; Peter Horby University of Oxford, ISARIC; David Hui, Chinese University of Hong Kong,

Hong Kong SAR; YaeJean Kim, Sungkyunkwan University, Samsung Medical Center, Korea; Srinivas Murthy, University of British Columbia, Canada; Norio

Ohmagari, M.D., M.Sc., Ph.D, WHO Collaborating Centra for Prevention, Preparedness and Response to Emerging Infectious Diseases, National CenterforGlobal Health and Medicine Hospital Toyama, Tokyo Japan; Yinzhong Shen Shanghai Public Health Clinical Center, Fudan University Naoki Shimizu; Tim

Uyeki, Centers for Disease Control and Prevention, USA. :

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Care 2016;20:75,22, Arabi YM, Mandourah Y, AlHameed F, etal. Corticosteroid Therapy for Critically Il! Patients with Middle East Respiratory Syndrome, Am J RespirCrit Care Med 2018;197:757-67.23. Laboratory testing for Middle East Respiratory Syndrome Coronavirus: Interim guidance [http:/Avww.who.int/csr/disease/coronavirus_infections/mers-Jaboratory-testing/en/}. Geneva: WHO; 2018.24, Ou X, Hua Y,Liu J, Gong C, Zhao W. Effect of high-flow nasal cannula oxygen therapyin adults with acute hypoxemic respiratory failure: a meta-

analysis of randomized controlled trials. CMAJ 2017;189:E260-E7.25. Lee MK, Choi J, Park B, et al. High flow nasal cannulae oxygen therapy In acute-moderate hypercapnic respiratory failure. Clin Respir J2018;12:2046-56.

26. Luo Y, OuR, Ling Y, Qin T.The therapeutic effect of high flow nasal cannula oxygen therapy for the first imported case of Middte East respiratory

syndrome to China [Chinese]. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2015;27:841-4. -

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27. Rechwerg B, Brochard L, Elliott MW,et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure, Eur

Respir J 2017;50,28.

isArabi YM, Arifi AA, Balkhy HH, et al. Clinical course and outcomes of critically ill patients with Middle East respiratory syndrome coronavirus infection.

Ann intern Med 2014;160:389-97.29. Leung CCH, Joynt GM, Gomersall CD, et al. Comparison of high-flow nasal cannula versus oxygen face mask for environmental bacterialcontamination in critically ill pneumonia patients: a randomized controlled crossover trial. J Hosp Infect 2019;101:84-7.30. Hui DS, Chow BK, Lo T,et al. Exhated air dispersion during high-low nasal cannula therapy versus CPAP via different masks. Eur Respir J 2019;53,31. Hul DS, Chow BK, Lo T,et af. Exhaled air dispersion during noninvasive ventilation via helmets anda total facemask. Chest 2015;147:1336-43,32. Detsky ME, Jivraj N, Adhikari NK, et al. Will This Patient Be Difficutt to Intubate?: The Rational Clinical Examination Systematic Review. JAMA

2019;321:493-503.33, Fan E, Del Sorbo L, Gofigher EC, et al. An Official American Thoracic Society/European Soctety of Intensive Care Medicine/Society of Critical CareMedicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome, Am J Respir Crit Care Med

2017;195;1253-63.34. Rimensberger PC, Cheifelz IM, Pediatric Acute Lung Injury Consensus Conference G. Ventilatory support in children with pediatric acute respiratorydistress syndrome: proceadings from the Pediatric Acute Lung Injury Consensus Conference, Pediatr Crit Care Med 2015;16:S51-60.35, ARDS Network Tools. 2014, (Accessed 25 July, 2018, at htto//www.ardsnet.org/tools shtml.)

36. Amato MB, Meade MO, Slutsky AS,et al, Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015;372:747-56,37. Messerole E, Peine P, Wittkopp S, Marini JJ, Albert RK, The pragmatics of prone positioning. Am J Respir Crit Care Med 2002;165:1359-63,38. Guerin C, Relgnler J, Richard JC, etal. Prone positioning In severe acute respiratory distress syndrome, N Engl J Med 2013;368:2159-68,39, National Heart L, and Blood Institute Acute Respiratory Distress Syndrome Cinical Trials Network,, Wiedemann HP, Wheeler AP,et al. Comparisonof two fluld-management strategies in acute lung injury. N Engl J Med 2006;354:2564-75,40. Briel M, Meade M, Mercat A,et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress

syndrome: systematic review and meta-analysis. JAMA 2010;303:865-73.

4. Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial Investigators, Cavalcanti AB, Suzumura EA, et all. Effect of

Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEPon Mortality in Patients With Acute Respiratory Distress Syndrome: A

Randomized Clinical Trial, JAMA 2017;318:1335-45.42. Gollgher EC, Kavanagh BP, Rubenfeld GD, et al. Oxygenation responseto positive end-expiratory pressure predicts mortality in acute respiratorydistress syndrome, A secondary analysis of the LOVS and ExPress trials. Am J Respir Crit Care Med 2014;190:70-6,43. Papazian L, Foret JM, Gacouin A,et al, Neuromuscular blockers in early acute respiratory distress syndrome. N Eng! J Med 2010;363:1 107-16.44, National Heart L, Blood Institute PCTN, Moss M, et al. Early Neuromuscutar Blockade in the Acute Respiratory Distress Syndrome. N Engl J Med2019;380:1997-2008, :

45, Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med

2018;378;1965-75,46. Goligher EC, Tomlinson G, Hajage D, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome and Posterior

Probability of Mortality Benefit in a Post Hoc Bayesian Analysis of a Randomized Cinical Trial, JAMA 2018;320:2251-9,47, Alshahrani MS,Sindi A, Aishamel F,et al. Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus, AnnIntensive Care 2018;8:3,48. Combes A, Brodie D, Bartlett R, et al. Position paper forthe organization of extracorporeal membrane oxygenation programs for acute respiratoryfailure in adult patients, Am J Respir Crit Care Med 2014;190:488-96.

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49, Levy MM, Evans LE, Rhodes A, The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Med 2018;44:925-8,50. Lamontagne F, Meade MO, Hebert PC, etal, Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilotrandomized controlled trial. Intensive Care Med 2016;42:542-50.51. Rochwerg B, Alhazzani W, Gibson A,et al. Fluid type and the useof renal replacement therapy in sepsis: a systematic review and network meta-analysis, Intensive Care Med 2015;41:1561-71.§2. Rochwerg B, Alhazzani W,Sindi A, et al. Fluid resuscitationin sepsis: a systematic review and network meta-analysis. Ann Intem Med2044;161:347-65.

53. Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheralintravenous catheters and central venous catheters, J Crit Care 2015;30:653 e9-17.

_

54, Schmidt GA, Girard TD, Kress UP, et al. Official Executive Summary of an American Thoracic Society/American College of Chest Physicians ClinicalPractice Guideline: Uberation from Mechanical Ventilation in Critically Ill Adults. Am J Respir Crit Care Med 2017;195:115-9.55. Muscedere J, Dodek P, Keenan S,et al. Comprehensive evidence-based clinical practice guidelines for ventilator-assoclated pneumonia: prevention.J Crit Care 2008;23:126-37.56. Klompas M, Branson R, Eichenwald EC,et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. InfectControl Hosp Epidemiol 2014;35:915-36.57. Marschall J, Merme! LA, Fakih M,et al. Strategies to preventcentral line-associated bloodstream infections in acute care hospitals: 2014 update.Infect Control Hosp Epidemiol 2014;35:753-74. .

© World Health Organization 2020. All rights reserved.

This is a draft. The content of this documentis not final, and the text may be subject to revisions before publication. The document

may notbe reviewed, abstracted, quoted, reproduced, transmitted, distributed, translated or adapted, in part or in whole, in any form orby any means without the permission of the World Health Organization.

10

Annex C. Decision Tool for Novel Coronavirus Assessment for Bureau of Quarantine and Hospitals(Version as of January 30, 2020)

| Respiratory|:Travel.|History of Case Category/ Intervention.‘ dafection:

|"

‘xposure! ky. pee

+ + + + Category: Patient Under Investigation (PUD

+ + + . Bureau of Quarantine (BoQ)© Gives mask and isolate PUT

+ + . + ¢ Collects and evaluates the BoQ Health Declaration Card® Endorses patient for admissionin a hospital.

+ . + + Arranges transportation of PUI to hospital

. + + +-| Hospitals

© Completes the case investigation form (CIF)« Trained hospital staff collects specimens (nasopharyngeal+ " + ° swab [NPS] andoral pharyngea! swab [OPS]) and sends to

RITM. (NPS/OPS mustbe collected upon admission and- + + - after 24 to 48 hours)

© Coordinates with RESU for reporting and transport of+ - . + specimens

+® Manages PUI accordingly

7 + “

Category: Person under Monitoring*

. . + + Bureau of Quarantine¢ Collects and evaluates the BoQ Health Declaration Card« Advises person to go on self-quarantine for 14 days,

monitor body temperature daily, and observe any signs andsymptoms of respiratory infection,

e If symptoms worsen, immediately notify the nearest- . + - hospital for consultation and provide travel history

Centers for Health Development© Monitor strictly those who are self-quarantined

*Anyone who came from

otherpartsoftheworld

withconfirmed2019-nCoV_ARD infection except China, has no_historyof. . ° + exposure, but with fever and/or cough, is considered Person

underMonitoring and is advised to go on self-quarantine for14 days

1 History of exposure Include:a, clase contact who took care, handled specimens and/or lived with a confirmed case of 2019-nCovV infection; or

* Close contactis defined as:© Health care associated exposure, including providing direct care for nCoV patients, working with health care workers infected with

novel coronavirus, visiting patients or staying in the same close environment as a nCoV patiento Working together in close proximity or sharing the same classroom environment with a nCoV patiento Traveling together with a nCoVpatient in any kind of conveyanceo Living in the same household as a nCoV patient

b, visiting/working in a live animal market in Chinac. direct contact with animals in China with circulating 2019-nCoV in human and animals

Annex D. Interim Case Reporting Form for 2019 Novel Coronavirus (2019-nCoV) of Confirmed And Probable Cases

eeSSSR elgerrrecLiceya WHO Case ID (International):—Interim case reporting form for 2019 Novel Coronavirus (2019-nCoV)of confirmed and probable cases

WHO Minimum Data Set Report Form

Date of reporting to national health authority: LEILDYVLMILMYLYILYILYILYIReporting institution:

Reporting country:Case classification: 0 Confirmed a Probable

Detected at paint of entry ONo oaYes o Unknown If yes, date LO JLDVLMILMI/LYILYILYILYISection 1: Patient information

Unique Case Identifier (used in country):Date ofBirth: LDJLO_V/LMILM.VLYILYILYILYJ or estimated age: |_JL_JIL_] in years

if < 1 year old, {__]L__] in months orif < 1 month, L_]L_] in daysSex at birth: 0 Male o Female

Place where the case was diagnosed: Country;Admin Level 1 (province): Admin Level 2 (district):

Patient usual place ofresidency: Country:Admin Level 1 (province): Admin Level 2 (district):

Section 2: Clinical informationPatient clinical courseDate of onset of symptoms: LOJLDYVLMILMVLYILYILYILYI a Asymptomatic oo UnknownAdmission to hospital: oNo o Yes o UnknownFirst date of admission to hospital: LD_JLD_/LMILMV/LYILYILYILYName of hospital:Date ofisolation: LDOILDYLMILMVIILYILYILYIWas the patient ventilated: oNo oYes a UnknownHealth status (circle) at time of reporting: recovered/ notrecovered /death / unknown

Date of death,if applicable: LOILPVLMILMVLYILYILYALY]Patient symptoms (check all reported symptoms):

« History offever / chills o Shortnessof breath o Pain (check all that apply)co General weakness o Diarrhoea ( ) Muscular ( ) Chest

o Cough o Nausea/vomiting ( ) Abdominal (_ ) Jointa Sore throat a Headacheo Runny nose a Irritability/Confusiono Other, specify

Patient signs :

Temperature: |_J[_JL_} a°C /aFCheck all observed signs:

& Pharyngea exudate a Coma a Abnormal lung X-Rayfindingso Conjunctival injection b Dyspnea / tachypnea0 Seizure o Abnormal lung auscultationa Other, specify:

Underlying conditions and comorbidity (check all that apply):

a Pregnancy (trimester: ) a Post-partum (< 6 weeks)

0 Cardiovascular disease, including hypertension a Immunodeficiency, including HIV

o Diabetes a Renal disease

o Liverdisease a Chronic lung disease

a Chronic neurological or neuromuscular disease a Malignancy

a Other, specify:

Section 3: Exposure and travel information in the 14 days prior to symptom onset(prior to reportingifasymptomatic)Occupation: (tick any that apply)

0D Student 0 Health care worker a Other, specify:

p Working with animals 0 Health laboratory worker

Has the patient travelled in the 14 days prior to symptom onset? 0 No o Yes o Unknown

If yes, please specify the places the patient travelled:Country City

1.

2,

3.

Has the patient visited any health care facility(ies) in the 14 days prior to symptom onset? oNo oaYes ao Unknown

Has the patient had close contact! with a person with acute respiratory infection in the 14 days prior to symptom onset?aNo oYes oUnknownIf yes, contact setting (check all that apply):

c Health care setting o Family setting a Work place a Unknown =o Other, specify:Has the patient had contact with a probable or confirmed case in the 14 days prior to symptom onset? :

oNo a Yes o UnknownIf yes, please list unique case identifiers of all probable or confirmed cases:Case 1 identifier. Case2 identifier. Case 3 identifier.

If yes, contact setting (checkall that apply):

a Health care setting u Family setting a Workplace o Unknown1cOther, specify:If yes, location/city/country for exposure:

Have you visited any live animal markets in the 14 days prior to symptom onset? oNo oaYes o UnknownIf yes, location/city/country for exposure:

Section 4: Laboratory InformationName of confirming laboratory: :

Please specify which assay was used: Sequencing done?: o Yes go No o Unknown

Date of laboratory confirmation: _D_JLD_I/LMILM_VLYILYILYILYI

1 Close contact’ is defined as: 1. Health care associated exposure, including providing direct care for nCoV patients, working with health care workers

infected with novel coronavirus, visiting patients or staying in the same close environment of a nCoV patient. 2. Working together in close proximity orsharing the same classroom environment with a with nCoV patient. 3. Traveling together with nCoV patientin any kind of conveyance. 4. Living in thesame household as a nCoV patient

Republic ofthe Philippines

Department ofHealth *

OFFICE OF THE SECRETARY

February 4, 2020

DEPARTMENT MEMORANDUMNo. 2020 - 0062

TO: ALL _UNDERSECRETARIES_AND_ ASSISTANT SECRETARIES;MINISTER _OF HEALTH - BANGSAMORO_ AUTONOMOUSREGION IN MUSLIM MINDANAO (MOH-BARMM); CENTERSFOR HEALTH DEVELOPMENT (CHD), BUREAU AND SERVICEDIRECTORS; EXECUTIVE DIRECTORS OF SPECIALTYHOSPITALS; CHIEFS OF MEDICAL CENTERS, HOSPITALSAND SANITARIA: AND OTHERS CONCERNED

SUBJECT: Guidelines on the Standards of Airborne Infection Isolation Roomand_ Conversion of Private Rooms and/or Wards into TemporaryIsolation Rooms for the Management of Patients Under Investigation(PUD for 2019 Novel Coronavirus (nCoV)

In response to the current or potential influx of Patients Under Investigation (PUI) for2019 Novel Coronavirus (nCoV)in our health facilities, all DOH Hospitals are hereby urged tocomply with the patient placement guidelines and isolation standards adopted from the CDCGuidelines and Standards for Transmission-based Precautions. This shall facilitate themanagement of PUIs and prevent the transmission ofthe virus within the health facility.

I. For health facilities with Airborne Infection Isolation Room (AIIR), the followingstandards shall be followed:

A. Isolation of Patients Under Investigation for nCoV Patients1. Place patient with known or suspected nCoV2. Airborne Infection Isolation Room (AIIR).3. While transfer to AIIR or discharge from the facility is pending, put face mask on the

patient and isolate in an examination room with the door closed. The patient must notbe placed in any room where room exhaustis re-circulated within the buildingwithout high-efficiency particulate air (HEPA) filtration.

4. Follow CDC guidelines on placement of patient with known or suspected nCoVinfection and adhere to standard, contact, and airborne precautions (ANNEX A).

B. Standards of Airborne Infection Isolation Room (ATER)1. ATER must be single-occupancy rooms with negative pressure relative to the

surrounding areas.2. There must be at least six (6) air changes per hour, or twelve (12) air changes per

hour for newly constructed or renovated rooms.

Building i, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1113, 1108, 1135Direct Line: 711-9502; 711-9503 Fax: 743-1829 @ URL: http:/www.doh.gov.ph; e-mail: ftduque@doh.gov.ph

6.

Air exhaust should be directed away from people and air intakes. If this is notpossible, air mustbe filtered through a HEPA filter before recirculation.Doors must be kept closed except when entering or leaving the room. Minimizeunnecessary entry and exit.

. Air pressure must be monitored daily with visual indicators (e.g smoke tubes, flutterstrips), regardless of the presence of differential pressure sensing devices (e.g.manometers).Forthe standard floor plan for ATIR, refer to ANNEX B.

i. Forfacilities with limited Airborne Infection Isolation Rooms, private rooms may beutilized for the management of PUIs.

A. Conversion of Single Private RoomFor the conversion of private rooms to isolation rooms, the following guidelines must befollowed:

1,

2.

Useprivate roomsat the end of the hallway for conversion into a temporary isolationroom. It must be away from the stairs and nurses’ station.Keep doors closed except when entering or leaving the room. Entry and exit shouldbe minimized.Keep the windows in the converted isolation rooms open regardless of use and non-use ofair conditioning. Windows connecting to hallways should not be opened.Theuse of air conditioning in the isolation room is allowed provided it is not part ofthe general air conditioning system ofthe facility.Use temporary portable solutions, such as exhaust fans or unidirectional fans, tocreate a negative pressure environment in the converted area. Discharge air directlyoutside, away from people and air intakes, or through HEPA filters beforeintroducing to other air spaces.All healthcare personnel shall strictly adhere to hand hygiene following the WorldHealth Organization’s Multimodal Hand Hygiene Strategy: 5 Moments of HandHygiene.Place wall-mounted alcohol-based hand rubs at point of care and outside the isolationroom.Medical supplies needed for patient care shall be made readily available at point ofcare. .

Ensure that the relatives or carers of minors and elderly patients are provided withPersonal Protective Equipment (PPEs). Instructions on the appropriate use anddisposal of PPEs must be provided.

10. Refer to ANNEX C for the Proposed Floor Plan for Converted Private Room. Ifaccess to a lavatory in the ante room is not feasible, wall mounted alcohol-basedhandrubsare recommended.

B. Conversion of WardWards may also be utilized for the management of PUIs. For the conversion of wardsinto isolation rooms, the following guidelines must be followed:1.2.

Follow the same guidelines for conversion of private rooms.Place cohorted PUIs in a converted ward room provided that they have the sametestresults. Do not include patients with pending confirmatory test results in the cohort.

3. General ward rooms must have adequate ventilation with at least 60 L/s ofair flowper patient.

4. All patient beds should be placedat least three (3) feet apart with a curtain separatorfor privacy.

IIf. Exclusive Use of Converted Private Rooms and Wards

Private rooms and wards converted into isolation rooms must not be used for themanagement and treatment of patients other than PUIs until after appropriateenvironmental cleaning and disinfection procedures are undertaken.

IV. Additional Information on Isolation Rooms

Additional reference materials on establishment and types of isolation rooms are listedon ANNEX D.

For guidance andstrict compliance.

By Authority of the Secr of\Health:

LILIBETH C. DAVID, MD, MPH, MPM,CESO IUndersecretary of HealthHealth Facilities Infrastructure and Development Team

ANNEX A

CDC STANDARD, CONTACT, AND AIRBORNE INFECTION PRECAUTIONS FORPATIENT WITH KNOWN OR SUSPECTED 2019-nCoV

(Source: https://www.cdc.gov/coronavirus/2019-nCoV/hep/infection-control.html)

. Once in an Airborne Infection Isolation Room (AIIR), the patient’s facemask may beremoved. Transport and movement of the patient outside of the AIIR must be limited tomedically-essential purposes. When not in an AJR (e.g. during transport), patients mustwear a facemask to contain secretions.

2. Personnel entering the room must use PPEs, including respiratory protection (i.e. fit-testeddisposable N95 mask).

. Only essential personnel must enter the room. Staffing policies must bestrictly observed tominimize the numberof healthcare professionals (HCP) whoenter the room.

-4. Facilities must take precautions to minimize the risk of transmission and exposure to otherpatients and other HCP.

5. Facilities must keep a log ofall persons who provide care and enter the room orcare areas ofthesepatients.

6. Dedicated or disposable noncritical patient-care equipment must be used (e.g., bloodpressure cuffs). If equipment will be used for more than one patient, clean and disinfect suchequipment before use on another patient according to manufacturer’s instructions.

7. HCP entering the room after a patient vacates the room must use respiratory protection.Standard practice for pathogens spread by the airborne route (e.g., measles, tuberculosis) isto restrict unprotected individuals, including HCP, from entering a vacated room untilsufficient time has elapsed for enough air changes to removepotentially infectious particles.Currently, there is no data on how long 2019-nCoV remains infectious in the air. In theinterim, apply a similar time period before entering the room without respiratory protectionas used for pathogens spread bythe airborneroute (e.g., measles, tuberculosis). In addition,the room should undergo appropriate cleaning and surface disinfection before it is returnedto routine use. ,

HCP must perform hand hygiene before and after contacts with patients, potentiallyinfectious material and PPE, including gloves.

9. Healthcare facilities must ensure that hand hygiene supplies are readily available in everycare location.

ANNEX B

STANDARDS AND FLOOR PLAN FOR AIRBORNE INFECTION ISOLATION ROOM

Hospital: Departmentof Heaith

250-Bed (Level 3)ROOM DATA SHEET

HEALTH FACILITY

DEVELOPMENT BUREAU

Updated Reference: Department: Room Title: Reference Sheet Number:April 2016. NURSING WARDS ISOLATION ROOM (TYPICAL) 250B-NU-RDS-07A

FUNCTIONAL DESIGN REQUIREMENTS:This activity space provides facilities needed EQUIPMENT AND

QUANTITY REMARKSfor the following activities: ACCESSORY CHECKLIST

a, Patient arrives on foot, in wheelchair or on a stretcher. [retevision 4trolley Waste bin w/ yellow lining 1 infectious

b. Transfer of patient to a hospital bed froma Waste bin w/ black fining i generalwheelchair or a.stretcher trotley and vice versa ater Heater’ 4

c. Patient undresses/dresses In the vicinity of loot, bedhead 1

hospital bed, with or without assistance

d. Patient takes meal In bed or in sitting area FURNITURE AND QUANTITY REMARKS

e. Patient receives visitors FIXTURE CHECKLIST

f. Patient stores clothing and other personat Hospital bed, adjustable; with 1belongings adjustable side ralls

&. Patient requiresprivacy hair, upright; stacking 4h, Patient usestoilet and bath = 1

\. Patient uses monitoring/diagnostlc equipment Bench, cushioned 1

j. Physicians and nurses check on patients lable, side; with cabinet 1

k. Handwashifig’and other clean up activities iTable, overbed 1|. Nurse gives medication to patient joset, wardrobe 1

m. Nurse may feed or wash patient, in the absence of fm wall-hung. 1

avrelative or watcher Concealed floar- drain 1

Cabinet, PPE 1

Water closet iLavatory al

People involved: Shower set 11x Patient

2x Visitors ADDITIONAL EQUIPMENT &Quantity REMARKS

1x Resident Physician/ Medical Specialist ENGINEERING TERMINALS

1x Nurse or Nursing Aide jWindow curtain rail 1

Bedhead light w/ night tamp 1 fluorescent, 20Wote, 20A,2P,240V, duplex grounding type,universat

Planning Relationships: utlet, 10A,2P,240V, single 1 for emergency light@. Acessible, to Nurse Station Nurse cali station, emergency i w/ pendant switchb, Located at end portion of Nursing Ward (Outlet, antenna/Cable 1

¢. Clase to medical/surgical services Smoke Detector 1

Hospital: Department of Health

250-Bed (Level 3)ROOM DATA SHEET

HEALTH FACILITY

DEVELOPMENT BUREAU

Updated Reference: Department: Room Title: Reference Sheet Number:April 2016 NURSING WARDS | ISOLATION ROOM (TYPICAL).|250B-NU-RDS-07B

TECHNICAL DESIGN DATA:

ENVIRONMENTAL CONDITIONS DESIGN DATA ENVIRONMENTAL CONDITIONS DESIGN DATA

AIR LIGHTING AND VISUAL

Outdoor air temperature (°C) ave, local station temp, reading |seneral Mumination (LUX) 250

Room temperature (°C) 23. Night iHumination (LUX) 50

Mechanical ventilation Task illumination (LUX) 500

Volume (cu.m./tir.-person} 25 Color rendering essential:DESIRABLE:unnecessary

Velocity (m/min) “30. standbylignt. §=—==SSS*|eSSENTIALsdesirablesunnecessary

Pressure Differential: Emergencylight ESSENTIAL:desirable:unnecessary

Negative Pressure {Pa} 10 Daylight essential: DESIRABLE:unnecessary:

Positive Pressure (Pa) NA flew out essential:DESIRABLE:tinnecessary

reDustfitration ss|=8 8%-9996@4 micron Privacy ESSENTIAL:desirablesunnecessary

Humidity (RH) 50. Black aut essential:desirable: UNNECESSARY

cooling load {TR} ee O75 a |

SOUND SAFETY

Acceptable sound tevel (db) 40 Accessible hot surface:. NA

Speech privacy essential:DESIRABLE:unnecessary |iMaximum temperature (°C) NA

Quality which cannot be tonal Impact Domestic hot water: at lavatory

tolerated Maximum temperature (°C} 70

laccess limitmedical staff, felatives/watcher &

patientFire risk LOW: medium: high

other risks NA

Hospital: Departmentof Health

250-Bed (Level 3)ROOM DATA SHEET

HEALTH FACILITY

DEVELOPMENT BUREAU

Updated Reference: Department: Room Title: Reference Sheet Number:

April 2016 NURSING WARDS meena 250B-NU-RDS-07CTECHNICAL DESIGN DATA: LAYOUT OF ROOM AND SPACE COMPONENTS:

DIRECT SERVICES DESIGN DATA

Disposal hospital solid waste type: A & G 6000Hot Water

:

“required at shower a 3700 . 2300

Cold Water req'd at lav & toilet fixtures|

Drainage req'datlav, toilet fixt. & floor

Medica! Oxyger 30lbm@ 4.0 Bar 8Medical Vacuum 40 Ips @ 450mm Hg acompresedair|SONAsteam

vee tw vneeee were} ones sane NA cesses

Others suction outlet required

DIRECT DEMANDS ON FLOOR AND WALL

Loading NA

Spillage SUGHT;occasional:frequent- “ KEY SCALE 1:100 M

Foot Traffic light! MEDIUM:heavy”

1 Hospital bed, adjustable; with, 8 Console, bedhead; for nurse callWheel Traffic light: MEDIUM heavy. adjustable elde rails medical ges outlels, power:

2 Chair, upright; stacking outlets, lamp, etc,impacts NA 3 Footstool 8 Waste bin, infectious‘Abrasi N

4 Bench, cushioned 10 Waste bin, generatrasion A 8 Table, side; with cabinetP .

y 6 Table, overbed ANTE ROOM:Easy Maintenance ESSENTIAL desirable:unnecessary| 7 Closet, wardrobe 44 Lavatory, wall-hungVibration Free ESSENTIALidesirable:unnecessary 12 Concealad floor drain

413 Cabinet, PPEDoor Set bed, wheelchair, &

Stretcher trolley access SPACE DEMANDS {Total Minimum Space Required In sq.m.)Windows clear, sotar-control, Space Components- Minimum Space Required/Component {sq.m.)

privacy control

internal Glazing. hone

IREGULATIONS AND NOTES:.

ANNEX C

PROPOSED FLOOR PLAN FOR CONVERTED PRIVATE ROOM

3000.00

3500.00

6009.00

PROVIDE: ¢---------}-----ADDITIONAL

DOOR & WALL

2500.00

Ff

1400.00 1600.00

CONVERTED PRIVATE ROOM

KEY:

SPN

aOaran

9.10.

It.(2.5.

HOSPITAL BED, ADJUSTABLE; WITH

ADJUSTABLE SIDE RAILSCHAIR, UPRIGHT; STACKING

FOOTSTOOLBENCH, CUSHIONED

TABLE, SIDE; WITH CABINETTABLE, OVERBED

CLOSET, WARDROBE

CONSOLE, BEDHEAD; FOR NURSE CALL,MEDICAL GAS OUTLETS, POWER OUTLETS,LAMP, ETC.WASTE BIN; INFECTIOUSWASTE BIN; GENERAL

ANTE ROOM:

LAVATORY; WALL-HUNGCONCEALED FLOOR DRAIN

CABINET; PPE

~HE--> PROVIDE:WASH SINK & PPE CABINET

ANNEX D

ADDITIONAL REFERENCE MATERIALS ON ISOLATION ROOMS

. Administrative Order No. 2012-0012, “Rules and Regulations Governing the NewClassification ofHospitals and Other Health Facilities in the Philippines,” as amended.

Refer to A.O. No. 2012-0012-A, “Amendment to Administrative Order (A.O.) No. 2012-0012 entitled "Rules and Regulations Governing the New Classification of Hospitals andOther Health Facilities in the Philippines”

. Administrative Order No. 2016-0042, “Guidelines in the Application for Department ofHealth Permit to Construct (DOH-PTC)” .

Refer to the following documents:— Annex H-6A, “Checklist for Review of Floor Plans, Level 1 Hospital”— Annex H-6B, “Checklist for Review of Floor Plans, Level 2 Hospital”— Annex H-6C, “Checklist for Review of Floor Plans, Level 3 Hospital”

. Total Alliance Health Partners International (TAHP!), “International Health FacilityGuidelines”

Refer to ChapterIV,“Isolation Rooms” (Visit: https://bit.ly/3bbu45L)

. Centers for Disease Control and Prevention (2007). “2007 Guideline for IsolationPrecautions: Preventing Transmission of Infectious Agents in Healthcare Setting”, updatedJuly 2019. https://www.cde.gov/infectioncontrol/guidelines/isolation/index.html

ANNEX C(List of Medicines and Medica! Supplies)

Medicine Medical Supplies and Equipment

Antipyretic Monitoring

Paracetamol 500mg tabletsParacetamol 200mg/ ampule

Thermometer (Thermal scanneror digital)

Sphygmomanometer

Respiratory Medications: Pulse Oximeters

Lagundi 300mg tor 600mg tablets300mg/ 5mL, 60mL Syrup

Stethoscopes

Ipratropium + Salbutamol 500mcg + 2.5mgx2.5mL (unit dose) Respiratory Airway

Salbutamol 1mg/mL 2.5mL nebule Oxygen Tanks

Butamirate Citrate 50mg tablet Oxygen Cannula (Adult and Pediatric)

Anti-Inflammatory Medications: Bag Valve- Mask (Adult and Pediatric)

Hydrocortisone 100mg, 200mg or 500mgpowdervial

Laryngoscope and Blade (Adult andPediatric)

Antidiarrheal Medications Nebulizer

Oral Rehydration Salts Nebulizing kits

Loperamide 2mg Capsule ET Tubesof varying sizes

Others Circulation

Clonidine 75mcg/ tab Intravenous Set (IV Cannula,Clonidine 150 mcg/mL, 1mL ampule Macro/Microset)

Soluset

IV Fluids (PLR, PNSS, DSLR, DSIMB)Sterile water for IV meds preparation Syringes (lec, 3cc, 5ec, 10cc and 30 syringe)

Epinephrine ampule Sterile needles (varied gauges)

Others Supplies and Equipment

Surgical tapes of different sizes (for IVinsertion and intubation)

Cotton balls

Sterile gauze

Surgical gloves (sterile & non-sterile)

Tongue Depressor

Sterile cotton swab

Tourniquet

Isopropyl alcohol

Povidone Iodine

Disinfectant solutions

Surgical Masks

Gowns

Goggles/ Face shields

N95 Respirators

Liquid antibacterial hand soap

Bed linens, pillows and cases

Color coded solid wastes disposal bins andplastic bags

Wheel chair

IV Stand